Autumn Lake Healthcare At Ballenger Creek

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

containers, noting that the facility replaced them and that the resident and the family were satisfied with the resolution. When she reviewed the grievance, she said that there did not appear to be a resolution included for the complaint regarding LPN6, and there was no evidence of education provided to staff regarding abuse. An interview with Assistant Director of Nursing (ADON) 3 on 11/18/25 at 1:35 p.m. revealed she was involved in the grievance regarding LPN6's alleged verbal abuse. ADON3 gave the same account as GSC9 regarding the resolution of the grievance dated 9/5/25. ADON3 said she reviewed the resident's record with RP2 without any concerns noted, and this was related to the care plan meeting that was held on the same day. ADON3 confirmed the grievance did not appear to address the resolution or outcome of the alleged verbal/mental abuse by LPN6, and there was no evidence of education provided to staff regarding abuse. In

an interview with RN12 on 11/18/25 at 2:55 p.m., RN12 reviewed the grievance forms dated 9/5/25 and stated that she became aware of the alleged verbal abuse by Responsible Party (RP) 2 on 11/5/25 during Resident R5's care plan meeting. RN12 initiated the grievance form and submitted it to GS9 for processing, further explaining that GS9 would then follow up with the appropriate department or person, such as the Administrator or Director of Nursing (DON) 2. RN12 did not witness the incident and was only present

during the care plan meeting when RP2 reported the allegations. In an interview with the DON2 on 11/18/25 at 3:10 p.m., she reviewed the grievance dated 9/5/25 regarding LPN6's behavior and alleged verbal/mental abuse. She said the incident occurred on 9/4/25 and was brought to the facility's attention by RP2 at Resident R5's care plan meeting, along with complaints regarding the bowls and containers. DON2 confirmed that the alleged verbal abuse was not addressed in the grievance resolution, and there was no report made of the alleged verbal abuse. She also confirmed there was no education provided as a means of preventing potential verbal/mental abuse within the grievance investigation. In an interview on 11/19/25 at 3:30 p.m.,

the Administrator stated the complaints made by RP2 at the care plan meeting were not considered verbal abuse, saying, They just didn't want LPN6 assigned to her, when asked why the self-report was not made.

When asked about the outcome or resolution to the allegation of verbal/mental abuse, the Administrator said they obtained LPN6's statement and the resolution was documented in the grievance investigation; however, she was unable to point out the statement or the resolution, stating, it (the outcome) covered everything. There was no evidence of education provided to staff regarding abuse.

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Ballenger Creek

347 Ballenger Drive Frederick, MD 21701

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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

interview on 11/19/25 at 3:30 p.m., the Administrator stated the complaints made by RP2 at the care plan meeting were not considered verbal abuse, saying, They just didn't want LPN6 assigned to her, when asked why the self-report was not made. When asked about the outcome or resolution to the allegation of verbal/mental abuse, the Administrator said they obtained LPN6's statement and the resolution was documented in the grievance investigation; however, she was unable to point out the statement or the resolution, stating, it (the outcome) covered everything. She acknowledged there was no evidence of education provided to staff regarding abuse related to the grievance.

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Ballenger Creek

347 Ballenger Drive Frederick, MD 21701

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 0610 Level of Harm - Minimal harm or potential for actual harm

and there was no evidence to support that education was provided to staff following a report/allegation of suspected abuse. A review of the facility investigation of the allegation of physical abuse dated 8/18/25 revealed the facility determined the incident to be inconclusive. There was no evidence the facility provided education to staff regarding abuse after the conclusion of the investigation.

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

11/20/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Ballenger Creek

347 Ballenger Drive Frederick, MD 21701

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

medication to the patient. The nurse should be with them while they complete their medications and then sign off on that medication, adding that medication administration is not complete if it is left in the medicine cup on a bedside table, and that the nurse should return to administer the medications later when a patient is not ready.In an interview with LPN4 on 11/18/25 at 2:45 p.m., she said she had worked at the facility for approximately four (4) years. LPN4 defined medication administration as, Follow the five (5) rights, don't leave meds in a room at the bedside, and stay until the patient takes the meds. LPN4 said that if the resident refused the medications at that time, she would contact the provider to obtain orders for the resident to receive their medications later or document the refusal. LPN4 reviewed the MAR and agreed

she was the nurse who signed that she had given the morning medications to Resident R5 on 10/2/25, as well as the two (2) days prior. When asked to explain how a family member may find a medicine cup with medications

in it if they were documented in the MAR as having been administered, LPN4 responded, A nurse must have signed off that the patient took it, but did not ensure they had taken it, adding, but I never leave medication at the bedside. LPN4 acknowledged she had been trained in medication administration but could not recall the last time, stating, We're always getting education, probably at least quarterly. I had it within the last few months. In an interview with the Director of Nursing (DON2) on 11/18/25 at 3:10 p.m., when asked to define medication administration, DON2 said the nurse should follow the physician's orders to administer the medications and verify the medicines, checking the ten (10) rights, including identification, allergies, and the mode of delivery. The nurse should watch the patient take the medication, never leave it at the bedside, and then sign the MAR. When asked how a family member might find a medicine cup containing the medications if they were documented on the MAR as administered, DON2 responded, They should never find it on the bedside table. In an interview with the Administrator and DON on 11/19/25 at 3:30 p.m., when asked to define medication administration, the Administrator agreed with DON2's restatement of her previous statement from the day before. She stated LPN6 provided verbal education on medication administration, but not all nursing staff received it, adding that the requirement is annually, but .it usually happens quarterly on average. They agreed there was no evidence in the grievance file to support

the education provided to LPN6 or any other nursing.

Event ID:

Facility ID:

If continuation sheet