Autumn Lake Healthcare At Bridgepark

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on complaint, reviews of a medical record, and staff interview, it was determined that the nursing staff failed to: 1) follow a physicians orders for withholding a cardiovascular medication when the pulse rate was less than 100 and document the resident's pulse rate when administering the cardiovascular medication, and 2) correctly document the route the cardiovascular medication should be administered.

This was evident for 1 of 2 residents (Resident #1) reviewed during the complaint survey.The findings include:Review of Complaint 2662089 on 11/13/25 at 6:30 AM revealed a an allegation Resident #1 was not receiving quality of care at the facility.Resident #1 was admitted to the facility on [DATE] with diagnoses that include but not limited to being totally ventilator dependent, tracheostomy, and using a feeding tube for nutrition and hydration. Resident #1 is totally dependent upon the nursing staff for all aspects of his/her care. Resident #1 was sent out to the hospital on [DATE] for facial/head swelling.Review of Resident #1's medical record on 11/13/25 at 6:30 AM revealed a physician order, dated 09/05/25, instructing the nursing staff to administer the cardiovascular medication, Propranolol Hydrochloride, 10 milligrams, by mouth, every 8 hours, for tachycardia (a fast heart rate).

Hold the medication if Resident #1's heart rate is less than 100 beats per minute.A review of Resident #1's September and October 2025 Medication Administration Records (MAR) revealed the nursing staff were signing off as administering a dose of Propranolol to Resident #1 without documenting Resident #1's heart rate and confirming Resident #1's heart rate was less than 100.The nursing staff also failed to correct the route in Resident #1's medical record as administering the Propranolol as being administered through Resident #1's gastrostomy tube (feeding tube).In an interview with the Director of Nursing (DON) on 11/13/25 at 9:30 AM, the DON was not aware the nursing staff were not documenting a pulse rate when administering the cardiovascular medication Propranolol to Resident #1 nor that the route of administering was by mouth.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/13/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Bridgepark

4017 Liberty Heights Avenue Baltimore, MD 21207

SUMMARY STATEMENT OF DEFICIENCIES