Orchard Hill Rehabilitation And Healthcare Center

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility staff failed to notify the Resident's physician when the Resident's BiPap was not administered (Resident #5). This was evident for 1 of 16 residents reviewed

during a complaint survey.The findings include:Review of Resident #5's medical record on 10/14/25 revealed the Resident was admitted to the facility in September 2024 with a diagnosis to include acute and chronic respiratory failure with hypercapnia. Hypercapnia is a condition characterized by an excessive amount of carbon dioxide in the blood, often resulting from respiratory issues like chronic obstructive pulmonary disease (COPD) or hypoventilation. Further review of Resident #5's medical record revealed the Resident was discharged to the hospital on 9/9/25 and returned to the facility on [DATE REDACTED]. Review of the hospital Discharge summary dated [DATE REDACTED] states: Patient has a history of respiratory failure and CO2 (carbon dioxide) retention. Using a BiPap is critical. Review of Resident #5's physician orders revealed the Resident was ordered BiPap at bedtime and as needed for naps. Review of Resident October 2025 Treatment Administration Record revealed the Resident was not administered the BiPap on 10/3, 10/11 and 10/12/25. Review of nursing notes for those dates revealed no notification to the Resident's physician the Resident was not administered his/her BiPap. Interview with Resident #5's Physician (Staff #3) on 10/15/25 at 1:16 PM, the Physician stated she would expect the facility staff to notify her when the Resident's BiPap can not be administered. Interview with the Director of Nursing on 10/15/25 at 1:59 PM confirmed the facility staff failed to notify Resident #5's physician when the Resident's BiPap was not administered on 10/3, 10/11 and 10/12/2025.

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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on review of facility reported incidents, record review, and interview, it was determined the facility failed to report an injury of unknown origin within 2 hours to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 1 (#11) of 4 residents reviewed for 4 facility reported incidents

during a complaint survey.The findings include: On 10/16/25 at 7:19 AM a review of facility reported incident 2566844 was conducted and revealed Resident #11 had a displaced fracture of the right hip. Review of Resident #11's medical record revealed Resident #11 had a history that included dementia, failure to thrive, and multiple contractures. On 7/15/25 on the 3:00 PM to 11:00 PM shift, Resident #11 complained about right foot pain. Resident #11 was also observed with right foot swelling. The physician was notified and ordered for the right leg to be elevated on a pillow. On 7/16/25 the physician ordered an x-ray and doppler study. On 7/16/2025 at 11:12 PM, Resident #11's X-ray result of the right hip showed that there was a displaced fracture laterally. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. Review of Resident #11's MDS assessment with an assessment reference date of 7/16/25, Section GG, mobility, documented that Resident #11 was dependent on staff for all mobility. Review of the facility's investigation into the injury of unknown origin documented that the initial report was not sent to OHCQ until 7/18/25 at 6:25 PM. On 10/16/25 at 9:46 AM

an interview was conducted with the Director of Nursing (DON). The DON confirmed the finding and stated that Staff #14 was written up by the prior DON for failing to notify administration timely.

Event ID:

Facility ID:

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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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

Based on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#11) of 4 residents reviewed for 4 facility reported incidents during a complaint survey.The findings include: The MDS is part of

the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 10/16/25 at 7:19 AM a review of facility reported incident 2566844 was conducted and revealed Resident #11 had a displaced fracture of the right hip. Review of Resident #11's medical record revealed a 7/16/25 physician's order for an x-ray and doppler study. On 7/16/2025 at 11:12 PM, Resident #11's X-ray result of the right hip documented there was a displaced fracture laterally.

Resident #11 was sent to the emergency room for further evaluation. Review of Resident #11's July 2025 Medication Administration Record (MAR) documented the resident received Tramadol 50 mg. for pain management on 7/13/25 at 18:31 for a pain level of 6 and on 7/10/25 at 13:50 for a pain level of 7. Review of Resident #11's MDS with an assessment reference date of 7/16/25 failed to capture the fracture in Section I diagnoses and failed to capture the use of Tramadol, which is an opioid medication, in Section N, medications. On 10/16/25 at 2:00 PM an interview was conducted with the Regional Director of Case Management, Staff #16 who stated the facility was currently without an MDS coordinator, however they just hired 2 people that were coming on board. Reviewed with Staff #16 that the fracture was not captured on

the 7/16/25 MDS, Section I and the opioid was not captured in Section N. On 10/16/25 at 2:55 PM, Staff #16 confirmed the errors.

Residents Affected - Few

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

Event ID:

Facility ID:

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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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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 Residents Affected - Few

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

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** Based on medical record review and interview, it was determined that the facility failed to have a process in place to ensure that a baseline care plan was provided to the resident's representative within 48 hours of admission to the facility (Resident #3). This was evident for 1 of 16 residents reviewed during a complaint survey. The findings include: The baseline care plan is given to residents and their representatives within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive. During interview with Resident #3's representative (RP) on 10/14/25 at 9:06 AM, the RP stated he/she was never given a baseline care plan or had a meeting with the facility staff to discuss admission to the facility within the first 48 hours of admission. Review of Resident #3's medical record on 10/14/25 revealed the Resident was admitted to the facility on [DATE REDACTED] from the hospital for rehabilitation services. Further review of Resident #3's medical record revealed there was no evidence in the medical

record of a baseline care plan that was reviewed and given to the Resident's RP. The medical record review failed to reveal evidence that the facility offered the Resident's representative a summary of the baseline care plan that included initial goals, physician orders, therapy services, dietary services, and social services within 48 hours of the resident's admission to the facility. Interview with the Director of Nursing on 10/16/25 at 9:40 AM stated the process is on for baseline care plans is on admission the facility staff assess the Resident and generate a baseline care plan and social work staff review with the Resident in a navigation meeting within the first 48 hours of admission. The DON was asked if the baseline care plan is reviewed with the Resident's representative also. The DON stated it is reviewed with the Resident if they are their own RP and with the RP if they are not. Interview with the Director of Nursing on 10/16/25 at 11:20 AM confirmed the facility staff failed to review the baseline care plans with the Resident's RP on 5/2/25. During

interview with Resident #3 on 10/16/25 at 11:28 AM, the Resident stated he/she would have wanted his/her RP involved in the navigation meeting on 5/2/25 to review his/her baseline care plans.

Event ID:

Facility ID:

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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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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

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

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

review of facility documentation, medical record review and interview, it was determined the facility failed to follow professional standards of practice when administering medications (Resident #5). This was evident for 1 of 16 residents reviewed during a complaint survey. The findings include:The 6 rights of medication administration are the right patient, the right drug, the right does, the right route of administration, the right time, and the correct documentation. Review of Resident #5's medical record on 10/14/25 revealed the Resident was admitted to the facility in September 2024 with a diagnosis to include end stage renal disease and dependence on renal dialysis. The facility staff assessed the Resident on 7/13/25 to have a BIMS (Brief

Interview for Mental Status) of 15 out of 15 indicating the Resident's cognition is intact.Review of facility documentation on 10/15/25 revealed a written statement from Staff #22 on 8/7/25 that stated: 8/5/25 1st day without a preceptor as night shift supervisor. Had a nurse call out and I had to be on cart. Was not trained on the cart. I never thought about passing meds and it was too late it would have been too close because next doses were going to be due. A statement from Staff #23 on 8/5/25 stated: During med pass it was observed prior Nurse (Staff #22) has signed off on multiple medications as being pass for Resident #5.

Upon investigation Resident #5 stated to not have been medicated during the overnight shift.Review of Resident #5's August 2025 Medication Administration Record revealed Staff #22 signed off she administered the following medications on 8/5/25: Dasatinib 50 mg, Duloxetine 60 mg, Fenofibrate 145 mg, Ferrous Sulfate 325 mg, Folic Acid 1 mg, Pantoprazole 40 mg, [NAME]-Vite 1 tablet, Apixaban 2.5 mg and Midodrine 5 mg.Review of an Employee Performance Improvement Notification for Staff #22 on 8/18/25 revealed it stated it was a written notice for Omission of medications signed in medical record. Interview with Director of Nursing on 10/16/25 at 9:40 AM confirmed Staff #22 signed off he/she administered medications on 8/5/25 to Resident #5 that were not administered.

Residents Affected - Few

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

Event ID:

Facility ID:

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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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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 0677

On 10/16/25 at 1:10 PM an interview was conducted with the Director of Nursing (DON). The DON reviewed the shower logs with the surveyor and confirmed the findings.

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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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

mobility, documented that Resident #11 was dependent on staff for all mobility.

Level of Harm - Minimal harm or potential for actual harm

Further review of Resident #11's medical record failed to produce documentation from the time of swelling and the physician's order to elevate the leg on 7/15/25 at 21:56 until a change in condition note was initiated on 7/16/25 at 22:21 of the fracture. There was no documentation of an assessment of the swelling.

There was no specific pain assessment of the leg/ankle region. There was documentation on the July 2025 Treatment Administration Record (TAR) that pain was assessed every shift, but nothing about the status of

the resident related to the swelling, and the conversation with the physician when the physician ordered the x-ray.

Residents Affected - Few

On 10/16/25 at 9:46 AM the Director of Nursing was interviewed, and she confirmed the surveyor's findings that there was no other documentation or assessment of the resident.

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

Event ID:

Facility ID:

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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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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

August of wound measurements and evaluations.

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:

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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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

We are supposed to clock out at 3 PM and sometimes I don't get out until 5 PM. Today I had 14 patients that were all total care. I can't turn and reposition every 2 hours.

On 10/17/25 at 9:55 AM Staff #33 was interviewed and said, yes, we are short staffed. Showers can't get done and they are late on water pass. Therapy and dialysis patients take priority. Trays come up and trays are on the floor but can't get passed.

On 10/17/25 at 9:57 AM Staff #34 was interviewed and said, we are short staffed and can't get showers done. Nail care isn't getting done and some days beds are not made. We do not turn and reposition every 2 hours. The residents do lay wet, unfortunately. We have expressed concerns at town halls. The first day I oriented someone, and we had 18 patients. After that the new orientee did not come back because it is too much. 4) Review of facility documentation revealed: a) Staffing sheets were reviewed from 7/25/25 to 7/30/25 that confirmed the staff findings of GNA to patient ratios. On 7/25/25 on day and evening shift on Unit 1, the census was 35 and there were 2 GNAs which made it a 1 to 17 ratio. On Unit 3 the census was 37 and there were 2 GNAs which made it a 1 to 18/19 ratio. On Station 2 the census was 27 and there were 2 GNAs and on Unit 4 the Census was 28 and there were 2 GNAs. This pattern was repeated with 2 GNAs on day and evening shift for 7/26/25 to 7/29/25. On 7/30/25 there were 2 GNAs on each unit on day shift, however on the evening shift there were 3 GNAs on unit 1. b) Review of facility documentation on 10/15/25 revealed a written statement from Staff #22 on 8/7/25 that stated: 8/5/25 1st day without a preceptor as night shift supervisor. Had a nurse call out and I had to be on cart. Was not trained on the cart. I never thought about passing meds and it was too late it would have been too close because next doses were going to be due. A statement from Staff #23 on 8/5/25 stated: During med pass it was observed prior Nurse (Staff #22) has signed off on multiple medications as being pass for Resident #5. Upon investigation Resident #5 stated to not have been medicated during the overnight shift. 5) On 10/17/25 the staffing boards were observed in the 4 units of the facility. On Unit 1 the census was 34.

There were 2 GNAs for a 1:17 ratio, 1 RN, and 1 LPN. On Unit 2 the census was 27. There were 2 GNAs for a ratio of 1:13/14, and 2 RNs. On Unit 3 the census was 36 and there were 3 GNAs, however 1 GNA was split between unit 3 and unit 4. On Unit 4 the census was 27 and there were 2 GNAs (with 1 split between unit 3 and unit 4) and 2 LPNs.

On 10/17/25 at 10:00 AM an interview was conducted with the Director of Nursing (DON). The DON was informed of all staffing concerns. The DON stated, I figured all of the staff complained about staffing.

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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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 0732

Post nurse staffing information every day.

Level of Harm - Potential for minimal harm

Based on review of facility documentation and interview, it was determined the facility staff failed to maintain accurate nursing staffing data. This was evident during a complaint survey and was evident for 18 of 18 days reviewed.The findings include: On 10/14/25 at 9:30 AM the surveyor requested the actual worked nursing schedule for the time period 7/25/25 to 8/12/25. On 10/15/25 at 7:00 AM, while reviewing a complaint, the surveyor was looking at the actual worked nursing schedules that were given from the Director of Nursing (DON). It was found that the schedules did not match up with statements from an investigation of who worked on a particular day. At that time the surveyor requested time punches to correlate with the nursing schedules. On 10/16/25 at 11:30 AM an interview was conducted with Staff #15,

the Human Resources Director. Staff #15 stated that she was going through time punches, and she confirmed that the schedule that was given to the surveyor as the actual worked schedule was not correct.

Staff #15 stated, we have had 2 schedulers during this time period. They were not updating the On-shift scheduling and by the time I got involved in it, late into August, is when I found out about it. From that point

on we got a staffing person here. Staff #15 stated, the schedules at the time were schedules that should have been printed from the On-Shift, and they were the old schedules, and they were pulled. There was a book that she pulled from; however, the ones that were in the actual system is what was posted, and they still were not accurate.Review of the schedules with the time punches revealed every day there were people that should not have been on the schedule that were listed as worked and people that had to be added on the schedule that were not initially on the schedule.On 10/17/25 at 11:20 AM the DON was informed of the concerns with not keeping an accurate account of who actually worked in the building and assignment on any given day and shift.

Residents Affected - Many

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

Event ID:

Facility ID:

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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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation and staff interview, it was determined that facility staff failed to keep medication carts locked when unattended and discard medications/biologicals when expired. This was evident on 1 of 3 nursing units observed during random observations made during a complaint survey. The findings include: On [DATE REDACTED] at 8:14 AM observation was made of an unlocked and unattended medication cart sitting outside of room [ROOM NUMBER]. The nurse was in the room and could not be visualized from the hallway. Staff #5 came out of the room and asked the surveyor what she was doing. The surveyor informed Staff #5 that the medication cart was left unlocked and unattended and that she could not be visualized from the hallway.The surveyor opened the top drawer of the medication cart and observed an opened 20 ml. vial of sterile water. There was no date opened on the bottle of sterile water. Also observed in the top right section of the first drawer was an insulin pen for Resident #14. The insulin was opened on [DATE REDACTED]. There was a second Insulin, Lispro, that was opened with no date opened. A third insulin, Aspart for Resident #14 did not have a date opened on the insulin pen and the seal was broken. There was also an opened Lispro insulin for Resident #3 that was opened on [DATE REDACTED] and an opened insulin Aspart that did not have a name and the seal was broken.According to the National Institute of Health, once the sterile water vial has been punctured and fluid has been removed, the container should be discarded no later than 4 hours after initial closure puncture.According to the manufacturer's instructions, the insulin should be dated when opened and should be discarded 28 days after opening.On [DATE REDACTED] at 12:22 PM the Director of Nursing (DON) was informed of the observation. The DON stated that the staff had received education about locking medication carts.

Event ID:

Facility ID:

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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

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Orchard Hill Rehabilitation and Healthcare Center

111 West Road Towson, MD 21204

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)

Federal health inspectors cited ORCHARD HILL REHABILITATION AND HEALTHCARE CENTER in TOWSON, MD for a deficiency under regulatory tag F-F0842 during a complaint investigation conducted on 2025-10-17.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 12 deficiencies cited during this inspection of ORCHARD HILL REHABILITATION AND HEALTHCARE CENTER.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-12-22.