Autumn Lake Healthcare At Loch Raven

F 0658

Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interview, it was determined that facility staff failed to follow a physician's order.

This was evident for 1 (#111) of 2 residents reviewed for pain management.The findings include:A medical

record review for Resident #111 on 9/9/25 at 9:43 AM revealed a medication administration record (MAR) for May of 2025, which noted the resident was ordered an opioid 10 mg as needed every 4 hours for a pain level of 7-10. However, on the following dates and times facility staff failed to follow the physicians orders and gave the medications for a pain level less than 7; 5/7 at 9:00 PM for pain level of 6, 5/9 at 1:22 PM for a pain level of 0, 5/13 at 12:09 AM for a pain level of 0, 5/14 at 6:30 PM for a pain level of 6, 5/17 at 1:18 PM for a pain level of 0, 5/27 at 9:44 PM for a pain level of 6, 5/28 at 6:00 PM for a pain level of 0, 5/28 at 11:59 PM of a pain level of 6, 5/29 at 2:15 PM for a pain level of 0, 5/30 at 8:41 PM for a pain level of 6, and 5/31 at 10:10 AM for a pain level of 4. The following dates were for June 2025; 6/2 at 2:17 PM for a pain level of 0 and 6/5 at 5:08 PM for a pain level of 0. An interview with Licensed Practical Nurse (LPN) #34 on 9/10/25 12:21 PM revealed that she was aware that the medication was to be given based on the physician's parameters of a pain level of a 7-10. She reported Resident #111 was demanding when s/he requested their pain medication and would not give a pain score at times. Reviewed the MAR with LPN #34 when she documented a pain score of 0 on 6/5/25 and administered the pain medication. She reported she could not recall if the resident did not give a pain score or if it was a typographical error. When asked if she had documented a pain assessment in the progress notes she reported she had not. During an interview with

the Director of Nursing (DON) on 9/10/25 at 1:49 PM she reported staff were expected to provide and level of pain for the resident and then give the medication according to the parameters. The DON acknowledge

the concern.

Residents Affected - Few

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Loch Raven

8720 Emge Road Baltimore, MD 21234

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

blood sugar since she was diabetic and reported vomiting earlier in the day. Furthermore, she stated that

the change in condition form should have been fully completed prompting the nurse to do a thorough assessment. She stated that the nurse was an agency nurse and was not currently working at the facility.

Requested the last known contact for the nurse.

On 9/9/25 at 9:39 AM the concerns were reviewed with the Director of Nursing (DON) and she acknowledged the concerns.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/11/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Loch Raven

8720 Emge Road Baltimore, MD 21234

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, record review, and staff interviews, it was determined that the facility 1) failed to provide services for pressure ulcer for a new admission and 2) to document and provide ordered treatment to promote healing of pressure injuries. This was found to be evident for 2 (Resident #115 and Resident #113) of 4 residents reviewed for pressure injuries during the survey. The findings include:1) On 9/4/25 at 10:53 AM a review of a complaint received regarding Resident #115 revealed that the resident was sent to

the hospital from the facility 4 days after admission in 2023. The complainant reported that the resident's wounds had worsened, and s/he was diagnosed with sepsis because the wounds were infected.

Residents Affected - Few

A medical record review for Resident #115 on 9/8/25 at 5:03 PM revealed a discharge summary from the acute care hospital dated 6/8/23. It was documented that the resident came to the hospital after being bedbound at home with a sacral pressure ulcer. The wound care was ordered as follows; clean daily with normal saline, pat dry, and apply medihoney (a wound treatment ointment or gel) and cover with bordered foam. A review of the Admit/Readmit Screener completed on 6/8/23 for Resident #115 revealed the nurse documented that the resident had a sacral wound. A review of the physician orders revealed an order dated 6/8/23, read “clean with normal saline, pat dry apply Midihoney [medihoney] on the sacral wound and cover with bordered foam. One time a day for wound care”. However, review of the treatment administration record (TAR) revealed staff failed to provide treatment to the wound until 6/10/23, 2 days

after the resident was admitted . Further review revealed the resident was seen by the wound specialist on 6/12/23, and it was recommended that the resident had blood drawn and an x-ray of the sacral region to rule out an infection, however, this was not done because the resident was sent to the hospital that day for lethargy.

An interview with the Director of Nursing (DON) on 9/9/25 at 9:39 AM revealed her expectation was that staff would remove the sacral wound dressing while conducting the admission assessment (admit/readmit screener) and then provide the wound treatment as ordered by the physician. She stated that it was unacceptable to wait 2 days after the admission to provide wound treatment for the resident. 2) On 9/11/25 at 10:53 AM, Complaint #344422 was reviewed. The complaint alleged Resident #113 was not receiving proper care and treatment to prevent pressure wounds.

On 9/11/25 at 11:15 AM, a review of Resident #113's records was conducted. The resident has an order for wound care to be completed daily and as needed and an order for the resident to be turned and repositioned. In the Treatment administration record, the facility did not document wound care on 6/10/24 and 6/17/24. In the task documentation survey report, the facility did not document Resident #113 being turned and repositioned for 6/4/24 Night, 6/8/24 Day and Night, 6/10/24 Night, 6/12/24 Night, 6/13/24 Evening and Night, 6/14/24 Day, 6/15/24 Night, 6/16/24 Night, 6/17/24 Day and Evening. The facility documented the resident was not being turned and repositioned on 6/5/24 and 6/15/24.

On 9/11/25 at 11:45 AM, an interview was conducted with the Director of Nursing (DON). When asked what is expected from nurses when documenting wound care, The DON stated that the nurses completing the wound care are expected to document the treatment and description of the wound. When asked who is responsible for documenting the wound care is expected to document the treatment in the TAR, the Person completing wound care for resident should be documenting the wound care completed in the TAR. This surveyor told the DON of missing documentation for wound care and turning and repositioning for Resident #113. The DON was made aware of concerns with documentation and resident not being turned as evidenced by task documentation.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet