Autumn Lake Healthcare Post-acute Care Center

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on record reviews and staff interviews, it was determined that the facility failed to review and revise

the care plan after each Minimum Data Set (MDS) assessment known as required . This was evident for 1 (Resident #32) out of 2 residents selected for Dialysis review during the survey.Findings include:The Centers for Medicare & Medicaid Services (CMS) defines the Minimum Data Set (MDS) as a standardized, comprehensive assessment of all residents in Medicare or Medicaid-certified nursing homes and swing beds. It is a tool used to gather information on resident strengths and needs, develop individualized care plans, and is used for Medicare/Medicaid reimbursement and quality of care. Section N (High-Risk Drug Classes) of the MDS, is used to document the resident's medication status for injections, high-risk drug classes, and medication-related problems.On 11/20/2025 at 11:40 AM during record review of resident #32,

the resident Care Plan (dated 9/11/25) revealed Resident is on Anticoagulant therapy related to cardiac disease process; Date Initiated: 06/06/2023; and Revision on: 09/15/2025. However, further record review revealed no current anticoagulant therapy orders. The resident's last anticoagulant therapy (Heparin) was ordered on 10/15/24 and discontinued 2/4/25; the Care Plan was not updated to reflect this change, despite

the MDS properly reflecting the change during 3 cycles of reviews.On 11/20/2025 at 12:08 PM during

record review of resident #32, this Surveyor reviewed the Minimum Data Set (MDS), Section N (High-Risk Drug Classes), which is used to document the resident's medication status for injections, high-risk drug classes, and medication-related problems. It revealed an answer of ‘Yes' indicating that the resident was receiving Anticoagulant therapy on the 9/13/24: Annual and 12/14/24: Quarterly assessments. Additionally,

after the Heparin orders were discontinued on 2/4/25, the MDS, Section N was then answered ‘No' during

the 3/16/25: Quarterly, 6/16/25: Quarterly, and 9/14/25: Annual assessments for Anticoagulant therapy.On 11/21/2025 at 12:21 PM during an interview with LPN Unit Manager staff # 14 and MDS Coordinator staff #23, when asked who is responsible for discontinuing or updating the resident care plan, MDS Coordinator staff #23 stated the unit manager is responsible for updating the Care Plan with any changes. The Surveyor then asked, how are medication orders and care plan changes monitored; the Unit Manager staff #14 stated orders are ran every 24hrs by the Unit Manager and Care Plan discussions and updates are done weekly on the unit. When asked if this Care Plan accurately reflected the current Anticoagulant therapy, the Unit Manager staff #14, agreed No.

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

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare Post-Acute Care Center

5009 Frankford Avenue Baltimore, MD 21206

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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

Review of the Chain of Custody Record revealed that the facility had received 28 doses of Methadone to be used from 11/20/24 to 12/16/24. The record also states that there is 102 mg (1st dose split) in each bottle, with 14 bottles received. It was documented on the form that Resident #208 was receiving one dose a day from 11/21/24 to 12/16/24. However, Resident #208 only signed off on 11/20/24 through to 12/2/24 that

they received the methadone. From 12/3/24 through 12/16/24, the form was only documented by the nurse giving the methadone with no resident sign-off. The next chain of custody record was not until 12/31/24, with the dosage split into separate bottles for the AM and PM dosage as requested by the DON #2 to the Methadone Program.

1. 4. 11/18/2025 8:15 AM during initial observation and interview with resident #117, a medication cup with

approximately 30 mL of light-yellow liquid was observed on the bedside table. When this Surveyor asked

the resident what it was, the resident stated oh, this was my medicine I had to take; the resident was unable to state the name or reason of the medication. During this encounter, CMA Staff #15 came to the resident door peering in during our interaction; the Surveyor asked the staff member, while pointing to the medicine cup, what medication was left at the bedside, staff #15 stated that was Lactulose. Staff #15 also stated the resident does not take all of the medications at once; I come back periodically until the resident takes them all.

Surveyor then went to the Medication Cart with staff #15, it was in the Dining Hall directly across from Resident #117's room; however, the cart was away from the entrance of the door and out of view of the resident. While at the medication cart with staff #15, the Surveyor observed the medication administration

record of Resident #117 with staff #15, it revealed a medication time to be given of 10:00 AM and order for Lactulose Oral Solution 10 GM/15ML (Lactulose) Give 30 ml by mouth one time a day for Hepatic Encephalopathy. This order was not charted as given, despite being left unattended by staff at bedside, prior to the Surveyor's 8:15 AM observation; nearly 2 hours prior to the medication ordered time.

On 11/18/2025 at 11:00 AM during interview with Director of Nursing staff #2 and Nursing Home Administrator staff #1, this Surveyor notified them of the observed medication at bedside left unattended by CMA staff #15 and the early administration. When asked if medications were ok to leave at bedside for residents to take on their own and the early timing, both the DON and NHA stated No.

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

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

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare Post-Acute Care Center

5009 Frankford Avenue Baltimore, MD 21206

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 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

until 12/16/24. It was discontinued at 11:31 AM on 11/20/24. The next transcribed order stated Methadone HCL Oral Solution 10 MG/5ML, give 10 mL by mouth two times a day for substance abuse. Hold for systolic B/P less than 110 on dialysis days. May give after dialysis and was started on 11/20/24 at 6 PM, and again should have lasted until 12/16/24. It was noted on the Licensed Nurse administration Record that the resident did not miss any doses from 12/16/24 through to 12/30/24; however, the facility only received 14 bottles for use from 11/20 to 12/16/24, which would have made the methadone last until 12/3/24. The resident would not have had enough to last from 12/4/24 through to 12/16/24, and especially not through to 12/30/24 when the next refill was requested.Review of the Chain of Custody Record revealed that the facility had received 28 doses to be used from 11/20/24 to 12/16/24. The record also stated that there was 102 mg (1st dose split) in each bottle, with 14 bottles received. It was documented on the form that Resident #208 was receiving one dose a day from 11/21/24 through to 12/16/24. However, Resident #208 only signed off on 11/20/24 through to 12/2/24 that they received the methadone. From 12/3/24 through 12/16/24, the form was only documented by the nurse giving the methadone with no resident sign-off. The next chain of custody record was not until 12/31/24, with the dosage split into separate bottles for the AM and PM dosage as requested by the DON #2 to the Methadone Program.

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

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare Post-Acute Care Center

5009 Frankford Avenue Baltimore, MD 21206

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 0760 Level of Harm - Minimal harm or potential for actual harm

split) in each bottle, with 14 bottles received. It was documented on the form that Resident #208 was receiving one dose a day from 11/21/24 through to 12/16/24. The next chain of custody record was not until 12/31/24, with the dosage split into separate bottles for the AM and PM dosage as requested by the DON #2 to the Methadone Program.

Residents Affected - Few

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

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

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare Post-Acute Care Center

5009 Frankford Avenue Baltimore, MD 21206

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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

discharged Within the Last Six Months form indicating the residents were discharged home. In response

the NHA staff #1 stated 'my MDS Coordinator completed the form and likely put the wrong discharge information, the residents were discharged to hospital, let me look into it'.

On 11/24/2025 at 4:05 PM during a follow-up interview with NHA staff #1, the Surveyor asked for further information regarding the discharge. The NHA staff #1 stated there is no other information, the residents were discharged home.

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

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare Post-Acute Care Center

5009 Frankford Avenue Baltimore, MD 21206

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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

1. 4. On 11/21/2025 at 10:22 AM the surveyor observed a red biohazard bag inside a carboard box on the

floor; dirty linen uncovered with personal resident clothing items. In the clean utility room, the surveyor observed that there were no paper towels in the towel container near the sink and there were O2 tanks both full and empty in holders on the left side of the wall, an old call bell and cord were lying on the floor.

On 11/24/2025 at 4:13 PM the surveyor interviewed the housekeeping director, staff #19 regarding the environmental issues found on the third-floor clinical unit. Staff #19 stated that he does not have a schedule for stripping waxing the linoleum floors in the facility. Additionally, staff #19 stated that facility perform deep cleaning of resident rooms monthly but did not provide any documentation to support this statement. Staff #19 stated that facility utilizes the TELS system to document and report environmental issues to the housekeeping and maintenance departments.

These deficiencies were discussed with the DON and Administrator prior to and during the exit conference

on 11/24/2025.

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

Event ID:

Facility ID:

If continuation sheet