Autumn Lake Healthcare At Crofton

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on record review and staff interview, it was determined that the facility failed to protect a resident from abuse. This was evident for 1 (Resident #199) out of 12 residents reviewed for abuse. The findings include: On 9/24/2025 at 10:45 AM, a review of Facility Reported Incident #311885 was conducted. The incident was in regard to an allegation of Employee to Resident abuse, where Staff #35 was alleged to have shoved incorrect medications into Resident #199's mouth despite the resident refusing the medication. On 9/24/2025 at 11:29 AM, a review of the Resident #199's progress notes was conducted. In the Provider notes from 2/28/2025 at 2:42 PM, the provider stated, The patient is being evaluated for a follow-up regarding a medication administration error. It was reported that the patient inadvertently received losartan and gabapentin. On 9/24/2025 at 11:38 AM, a review of the witness statement was conducted. The witness, Staff #36, stated that they witnessed Resident #199 yelling at Staff #35, stating Im not taking this, what are you giving me. I don't take that medication. Staff #36 then witnessed Staff #35 put a spoon in Resident #199's mouth while the resident was yelling, what are you giving me, I should not have taken that. Staff #36 then asked Staff #35 what medications were given to Resident #199. Staff #35 stated that they gave the resident Gabapentin and Losartan. Staff #36 told Staff #35 that Resident #199 does not take those medications and that they made a medication error. On 9/24/2025 at 12:30 PM, a surveyor interviewed the Director of Nursing (DON) regarding a finding of substantiated abuse. The surveyor noted the finding was based on a witness's statement. The DON questioned how the incident could be considered abuse without proof of forceful medication administration. The surveyor clarified that the resident's refusal of the medication, followed by its administration, constituted abuse.

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

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Crofton

2131 Davidsonville Road Crofton, MD 21114

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

On 9/25/2025 at 8:53 AM, the Director of Nursing (DON) was made aware of surveyor concerns.

Level of Harm - Minimal harm or potential for actual harm 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

09/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Crofton

2131 Davidsonville Road Crofton, MD 21114

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 record review and staff interviews, it was determined that the facility failed to prevent a significant medication error. This was evidenced in 1 (Resident #199) out of 6 residents reviewed for medications. The findings include: On 9/24/2025 at 10:45 AM, a review of Facility Reported Incident #311885 was conducted.

The incident was in regard to an allegation of Employee to Resident abuse, where Staff #35 was alleged to have shoved incorrect medications into Resident #199's mouth despite the resident refusing the medication. 9/24/2025 at 11:20 AM, an interview with the Director of Nursing (DON) was conducted. When asked about the facility's outcome of incident #311885, the DON stated that the facility determined the medication error to be substantiated and the alleged abuse to be inconclusive. On 9/24/2025 at 11:29 AM,

a review of Resident 199's progress notes was conducted. In the Provider notes from 2/28/2025 at 2:42 PM, the provider stated, The patient is being evaluated for a follow-up regarding a medication administration error. It was reported that the patient inadvertently received losartan [100 mg] and gabapentin [100 mg]. A comprehensive investigation has been initiated to examine the circumstances surrounding this medication administration error. Educational sessions have been conducted with both nursing staff and medical aides to ensure they recognize the potential side effects associated with the inadvertently administered medications. Primary symptoms to monitor related to losartan include hypotension and renal failure. In relation to gabapentin, the key signs to observe include the presence of hallucinations, excessive somnolence, altered mental status, excessive lethargy or fatigue, malaise, and generalized muscle weakness. The Director of Nursing has been apprised of the findings. A thorough investigation is currently underway to assess the systems involved. Losartan is a medication used to lower blood pressure. Gabapentin is an anticonvulsant medication used to treat seizures and nerve pain. On 9/24/2025 at 11:38 AM, a review of the witness statement was conducted. The witness, Staff #36, stated that they witnessed Resident #199 yelling at Staff #35, stating Im not taking this, what are you giving me. I don't take that medication. Staff #36 then witnessed Staff #35 put a spoon in Resident #199's mouth while

the resident was yelling, what are you giving me, I should not have taken that. Staff #36 then asked Staff #35 what medications were given to Resident #199. Staff #35 stated that they gave the resident Gabapentin and Losartan. Staff #36 told Staff #35 that Resident #199 does not take those medications and that they made a medication error.

Residents Affected - Few

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

Event ID:

Facility ID:

If continuation sheet