Autumn Lake Healthcare At Summit Park

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on resident interview, observations, and staff interviews, it was determined the facility failed to maintain a homelike environment. This was evident in 2 (Room A21 and Room D18) out of 9 rooms reviewed for environment. The findings include:1.) On 8/12/2025 at 8:12 AM, During an interview with Resident #4, the resident stated that their bathroom sink had no working hot water. This surveyor observed

the bathroom sink to only have the hot-water faucet handle to functioning. When opening the cold-water faucet handle there was no water coming out of the faucet. This surveyor made the Unit manager on the A-wing (Staff #2) aware of the findings. On 8/15/2025 at 2:15 PM, this surveyor asked the Director of Nursing (DON) about the progress of the malfunctioning water faucet in Resident #4's bathroom. The DON stated they were not aware but would address the concern.On 8/18/2025 at 2:44 PM, This surveyor verified with observation that the sink is now functioning. Furthermore, an interview was conducted with the Maintenance Director (Staff #20) and stated that on Friday 8/15/2025 a call to a plumber was made because the resident's pipe was clogged. Staff #20 confirmed that the plumber fixed the issue by replacing pipe that same day. 2.) On 8/26/2025 at 9:43 AM, an observation and interview was conducted with Resident #52. Resident #52 stated that the curtains in the room were always dusty and that staff was not cleaning them appropriately. The resident stated that there were black dots all over the door frame of the bathroom. This surveyor confirmed the resident's concerns and obtained photographs of the areas. The curtain on the window had large pieces of dust and white particles. The black dots on the door frame started on the top of the frame and extended to the wall above the door frame.On 8/26/2025 at 10:40 AM,

an interview was conducted with the Maintenance Director (Staff #20). This surveyor expressed Resident #52's concerns about the Black dots and Dusty curtains. Staff #20 stated they will address dust and particles on the curtains and the black dots on the wall and bathroom door frame.

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

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Summit Park

1502 Frederick Road Catonsville, MD 21228

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 0655 Level of Harm - Minimal harm or potential for actual harm

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:

Residents Affected - Few Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure that residents were provided with summaries of their baseline care plans including a list of their medications. This was evident for 1 (Resident #15) of 3 residents reviewed for baseline care plans.The findings include:On 8/14/2025 at 10:32 AM A Review of Resident #15's medical record was conducted. The review indicated that the resident was admitted on [DATE REDACTED] and a baseline care plan was completed on 1/24/25. However, the electronic copy of the baseline care plan had no signatures that indicated the resident had reviewed or was provided a summary of the baseline care plan. On 8/14/2025 at 10:52 AM The Director of Nursing (DON) was asked to provide evidence that a summary of baseline care plan was provided to Resident #15. On 8/14/2025 at 11:38 AM An interview with the social worker was conducted. The social worker reported that

the facility did not have evidence that the baseline care plan summary was provided to the resident. She further stated that the current facility process was to document a progress note to indicate that the baseline summary was reviewed and provided to residents. On 8/14/2025 at 11:48 AM Further review of Resident #15's progress notes failed to show any documentation that a baseline care plan summary was provided to

the resident. The social worker confirmed that there was no note on the resident's file that addressed baseline care plan. On 8/14/2025 at 11:52 AM Administrator and the DON were made aware of the concerns.

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

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Summit Park

1502 Frederick Road Catonsville, MD 21228

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 0656 Level of Harm - Minimal harm or potential for actual harm

confirmed that the resident did not have a care plan for the indwelling foley catheter. At this time she was made aware of the concern.

On 8/21/2025 at 12:20 PM the Director of Nursing was made aware of the concern and again on exit on 8/27/2025.

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

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Summit Park

1502 Frederick Road Catonsville, MD 21228

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

not get their diaper changed in a timely manner. On 8/21/2025 at 10:12 AM Review of Resident #126's medical record was conducted. The review revealed that the resident was admitted into the facility on 5/10/24 and was discharged to the hospital on 2/16/25. Further review of the records revealed MDS completed and accepted on 11/16/24 that indicated the resident was dependent on staff for toileting hygiene, oral hygiene, shower/bathe and personal hygiene. Also, MDS Section H for Bowel and Bladder indicated that the resident was always incontinent.On 8/21/2025 at 10:33 AM Facility was asked to provide documentation for bowel and bladder incontinence care provided to the resident for the months of January and February 2025. On 8/21/2025 at 11:05 AM The surveyor received documentation for bowel and bladder incontinence care from the facility for the month of January only. The review of these documents revealed several days in January (1, 3, 6, 8, 25, 26, and 28) that indicated the resident was not available to receive toileting hygiene care. Additionally, there was no documentation on 1/13, 1/20, 1/27, 1/29 and 1/30).

However, review of Resident #126 medication administration record and progress notes, revealed that the resident never left the facility.On 8/21/2025 at 11:25 AM The DON was asked to provide documentation that indicated the resident was not available to receive care in the facility.On 8/21/2025 at 12:00 PM An

interview with the DON was conducted. DON stated it was the expectation of facility staff to complete personal hygiene, bowel and bladder incontinence for the residents every shift. He further stated that it would be very unlikely for a resident to be away the entire shift for the staff to lack an opportunity to provide or assess for bladder and bowel incontinence. On 8/25/2025 at 12:30 PM The DON reported to the surveyor that the resident was in the facility for the days marked as resident not available. He also stated that there was no additional information that the resident was provided with toilet hygiene care. The surveyor notified the DON that this was a concern.

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

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Summit Park

1502 Frederick Road Catonsville, MD 21228

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 0689 Level of Harm - Minimal harm or potential for actual harm

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:

Residents Affected - Few Number of residents cited: Based on record review and interviews, it was determined that the facility failed to ensure the resident had

an identification wrist band on which led to the wrong resident having their blood drawn. This was evident for 1 (Resident #44) of 28 complaints that were reviewed during the annual survey. The Findings Include:

On 8/13/25 at 11:39 AM, complaint #330059 was reviewed and it mentioned that the resident had their blood drawn by mistake due to the resident not having an identification wrist band on. On 8/13/25 at 12:15 PM, the complainant was interviewed. They stated that on 12/9/2024, during a visit with the resident, they noticed that there was gauze and tape on the resident's hand. The complainant then asked the resident's roommate what had happened, they informed the complainant that the lab tech had come into their room and drew Resident #44's blood by mistake. The complainant stated that he asked the facility staff what had happened and they were unaware of the incident. The complainant stated that a grievance was then filed.

On 08/18/2025, at 11:21 AM, a review of the facility grievances that were filed in December of 2024 revealed that the complainant did report the incident to the facility on [DATE REDACTED]. The results, after the investigation, substantiated that the lab error did occur and that the resident did not have an armband on at

the time the error occurred.On 08/19/2025 at 12:14 PM, during an interview with the Assistant Director of Nursing, she confirmed that the incident had occurred. She stated that, following the facility's investigation into the incident, it was substantiated that Resident #44 did not have an identification wrist band on which led to the wrong resident's blood being drawn. At this time she was made aware of the concern.

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

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Summit Park

1502 Frederick Road Catonsville, MD 21228

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

Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or potential for actual harm

Based on resident interview, record review, and staff interview, it was determined that the facility failed to prevent a significant medication error. This was evident for 2 (Resident #105 and #52) out of 6 resident's

review for unnecessary medications. The findings include:1.) On 8/12/2025 at 11:45 AM, a review of Complaint #330061 was completed. The complaint alleged Resident #105 received the incorrect dose of medication.On 8/12/2025 at 12:02 PM, an interview with Resident #105's representative was conducted.

The Resident's representative stated in November of 2024, there was a med error.On 8/15/2025 at 10:04 AM, a review of Resident #105's progress notes was conducted. The change of condition note on 11/10/2024 stated that the resident received 2 mg of Clonazepam instead of the ordered 1 mg of Clonazepam. Order was placed to hold the next dose of Clonazepam, vital signs every shift, and to complete neuro checks every 24 hours. On 11/10/2024 at 00:15, the note stated, during med count writer found out that the clonazepam came in 1mg, so one tablet should've been given. Nurse Practitioner notified.On 8/15/2025 at 10:18 AM, a review of Resident #105's Medication Administration Record indicated that Staff #23 was the Licensed Practical Nurse who gave Clonazepam prior to the change of condition note and the order of Clonazepam being held. On 8/15/2025 at 10:49 AM, a review of Resident #105's orders was completed. The clonazepam Oral Tablet 0.5 mg Controlled Drug was ordered to give via G-Tube every 8 hours for seizures on 10/19/24 and discontinued on 11/9/24. The order was revised and stated, PLEASE GIVE ONLY ONE TABLET, on 11/9/24. On 8/15/2025 at 11:05 AM, a review of Facilities investigation was conducted. A statement from Staff #23 states the staff found out the medication was given incorrectly at narcotic count on change of shift on 11/9/2024 at 11:00 PM.On 8/15/2025 at 1:53 PM,

an interview was conducted with the Director of Nursing. When asked about the medication error, they stated medication error was confirmed and staff were educated. 2.) 8/26/2025 8:48 AM, a review of Complaint #330032 was conducted. The complaint stated that a nurse gave Resident #52 the wrong medication. The complaint extended from 2/20/2024 to 8/15/2025.On 8/26/2025 at 9:34 AM, a review of Resident #52's progress notes was conducted. In a change of condition note from 3/4/2025 at 5:39 PM, it stated, Med error, administer 4-unit lispro due to wrong identification of resident picture by name. MD and Supervisor was notified. Md recommend q6 b/s monitoring. Vital signs was stable; b/s 107 @ 5.39pm, 113 @ 11.54pm. pt alert x4, No sign of hypoglycemia or hyperglycemia. Non-adverse reactions noted. call light within reach. Family notified.On 8/26/2025 at 11:15 AM, a review of the facilities incident report regarding

the medication error was conducted. In the incident report, there was education provided to the Licensed Practical Nurse (Staff #22) who administered the medication to the incorrect resident (Resident #52) on 3/4/2025.On 8/26/2025 at 11:20 AM, an interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) was conducted. It was confirmed that Staff #22 made a medication error by not identifying the correct resident and giving a dose of 4 units of Lispro to the incorrect resident. Per the ADON, the nurse was placed back on 3-day orientation after the error and another competency was completed on 3/11/25.

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

08/27/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Summit Park

1502 Frederick Road Catonsville, MD 21228

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 0770

Provide timely, quality laboratory services/tests to meet the needs of residents.

Level of Harm - Minimal harm or potential for actual harm

Number of residents sampled: Number of residents cited:

Residents Affected - Few Based on record review and interview, it was determined that the facility failed to obtain laboratory tests as ordered by the physician. This was evident for 1 (Resident #120) of 27 residents reviewed during the investigation portion of the survey. The Findings Include: On 08/18/2025 at 7:27 AM, Resident #120's

record review revealed a change in condition stating the resident had a change in mental status with paranoid delusions on 6/17/2025. The physician placed an order to obtain a urine analysis (UA) to rule out

a possible urinary tract infection on 6/18/2025. On 08/18/2025 at 7:40 AM, a review of the resident's documented lab results revealed that there were no results for the ordered urine analysis. Further review revealed that there was no documentation of refusal. On 08/18/2025 at 1:52 PM, during an interview with

the Director of Nursing (DON), he explained that the reason the UA was not obtained was due to the resident refusing. When asked to provide documentation proof of refusal he stated that there was no documentation. At this time, and again at exit on 8/27/2025, the DON was made aware of the concern of

the order for the UA not being obtained.

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

Event ID:

Facility ID:

If continuation sheet