Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
16% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 19, 2025
Visit Reason
The inspection was conducted as part of the recertification survey to review the facility's compliance with regulations, specifically focusing on investigations of allegations of abuse.
Findings
The facility staff failed to complete thorough investigations for allegations of abuse in 2 of 5 investigations reviewed. Specifically, not all staff who worked during the alleged incidents were interviewed, which was confirmed by the Administrator.
Deficiencies (1)
Failure to complete thorough investigations for allegations of abuse, including not interviewing all staff who worked during the alleged incidents.
Report Facts
Investigations reviewed: 5
Investigations with deficient practice: 2
Staff working during alleged incident: 21
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Mar 5, 2024
Visit Reason
The inspection was conducted as part of an annual and complaint survey to assess compliance with regulatory requirements related to resident care, abuse prevention, reporting, investigation, activities of daily living, physician supervision, and medical record maintenance.
Findings
The facility was found deficient in multiple areas including failure to inform residents' responsible parties of medical changes and falls, failure to protect residents from abuse, failure to timely report abuse allegations, incomplete investigations, inadequate provision of activities of daily living, lack of physician supervision for significant weight loss, and failure to maintain accurate and secure medical records.
Deficiencies (8)
Facility staff failed to ensure a resident's responsible party was informed of a change in the medical regimen.
Facility staff failed to ensure a resident's responsible party was informed of a fall.
Facility failed to protect a resident from abuse by a staff member.
Facility failed to timely report an allegation of abuse to the State Office of Health Care Quality.
Facility staff failed to ensure a thorough investigation was conducted and maintain documentation of the investigation.
Facility staff failed to provide activities of daily living care in accordance with the resident's plan of care.
Facility staff failed to ensure that a physician sent a death certificate to a funeral home and failed to ensure physician supervision for a resident with significant weight loss.
Facility failed to safeguard resident-identifiable information and maintain accurate medical records.
Report Facts
Residents reviewed for abuse allegations: 17
Residents reviewed for ADLs: 4
Residents reviewed for death: 3
Residents reviewed for weight loss: 1
Residents in survey sample: 53
Weight loss percentage: 9.75
Shower documentation opportunities: 39
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #26 | Geriatric Nursing Assistant | Named in abuse finding for neglecting Resident #37 |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding multiple deficiencies and investigations |
| Staff #14 | Geriatric Nursing Assistant | Named in abuse allegation involving Resident #90 |
| Staff #21 | Medical Records Personnel | Interviewed regarding medical record errors and death certificate |
| Staff #27 | Geriatric Nursing Assistant | Interviewed regarding shower scheduling and documentation |
| Staff #29 | Licensed Practical Nurse | Interviewed regarding medication cart computer screen privacy |
| Staff #30 | Licensed Practical Nurse | Interviewed regarding medication cart computer screen privacy |
| Staff #8 | Social Worker | Interviewed regarding substitute decision maker and advanced directives for Resident #188 |
| Staff #32 | Registered Nurse | Wrote nursing note about open skin area for Resident #188 |
| Staff #33 | Nurse | Completed Weekly Skin Evaluation with inconsistent documentation for Resident #188 |
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 11
Date: Feb 12, 2024
Visit Reason
The inspection was conducted as an annual and complaint survey to assess compliance with regulatory requirements including resident care, medication management, infection control, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to maintain a homelike environment, inaccurate wound assessments, missed care plan meetings, inadequate assistance with activities of daily living, improper respiratory care, medication regimen review deficiencies, medication storage issues, failure to safeguard resident information, and lapses in infection prevention and control practices.
Deficiencies (11)
Facility failed to provide residents with a homelike environment, including damaged walls above sinks in multiple rooms.
Failed to accurately document wound assessments in a resident's medical record.
Failed to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment.
Failed to provide activities of daily living care in accordance with the resident's plan of care.
Failed to provide respiratory care consistent with professional standards for oxygen administration.
Failed to have a process ensuring medication irregularity reports were reviewed by the primary care physician and addressed timely.
Failed to ensure resident's drug regimen was free from unnecessary drugs.
Failed to limit as needed psychotropic medication from being prescribed for less than 14 days.
Failed to store medications appropriately according to standards of practice, including expired medications and unlocked medication carts.
Failed to safeguard resident-identifiable information and maintain accurate medical records.
Failed to ensure staff performed hand hygiene according to facility policy.
Report Facts
Residents observed with damaged environment: 15
Residents reviewed for pressure ulcers: 2
Residents reviewed for care planning: 5
Residents reviewed for ADLs: 4
Residents reviewed for medication regimen: 5
Medication doses documented: 34
Days without shower documented: 7
Days without shower documented: 9
Pulse ox readings missing: 4
Medication irregularity reports with comments: 6
Days psychotropic medication available: 30
Medication expiration dates observed: 3
Staff observed for hand hygiene: 7
Staff failed hand hygiene: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #31 | Wound Nurse Practitioner | Documented stage 3 pressure ulcer for Resident #17 |
| Staff #28 | Minimum Data Set (MDS) Coordinator | Interviewed regarding wound assessment coding for Resident #17 |
| Staff #8 | Social Worker | Interviewed about care plan meetings and advanced directives |
| Staff #27 | Geriatric Nursing Assistant (GNA) | Interviewed about shower scheduling and documentation |
| Staff #2 | Infection Preventionist/Staff Educator | Observed medication administration and discussed medication cart audits |
| Staff #34 | Licensed Practical Nurse (LPN) | Observed medication administration including expired medications |
| Staff #35 | Licensed Practical Nurse (LPN) | Observed medication administration and medication order review |
| Staff #6 | Unit Manager | Interviewed about medication cart restocking and education |
| Staff #21 | Medical Records Personnel | Interviewed about incorrect scanning of consult documents |
| Staff #32 | Registered Nurse | Documented skin evaluation for Resident #188 |
| Staff #33 | Nurse | Completed inconsistent skin evaluation documentation for Resident #188 |
| Staff #29 | Licensed Practical Nurse (LPN) | Interviewed about locking medication cart and computer screen |
| Staff #30 | Licensed Practical Nurse (LPN) | Interviewed about medication cart responsibility and locking |
Inspection Report
Annual Inspection
Deficiencies: 15
Date: Mar 29, 2019
Visit Reason
The facility underwent an annual Medicare/Medicaid survey to assess compliance with regulatory requirements including resident care, safety, and facility operations.
Findings
The survey identified multiple deficiencies including failure to promote resident dignity during feeding assistance, failure to keep a resident free from abuse, inaccurate resident assessments, failure to follow care plans, ineffective communication of physician orders, incomplete new hire competencies and annual evaluations for staff, medication errors including crushing medications on the Do Not Crush list, inadequate infection control practices, failure to serve therapeutic diets as prescribed, missing initial physician assessments in medical records, and failure to maintain essential equipment such as lift batteries.
Deficiencies (15)
Failed to enhance and promote a resident's dignity and respect while providing feeding assistance to a resident during lunch.
Failed to keep a resident free from abuse; employee was not immediately removed from duty after abuse allegation.
Failed to include required statement of resident's appeal rights and ombudsman contact information in written notice of transfer.
Failed to ensure Minimum Data Set (MDS) assessments accurately reflected resident's medication usage and dental condition.
Failed to follow resident's care plan related to nutritional intervention needs; staff unaware of feeding assistance requirements.
Failed to ensure effective communication and follow-up of neurology consultation orders for medication.
Failed to complete new hire skills competency assessments for Geriatric Nursing Assistants prior to independent work.
Failed to complete annual performance evaluations for Geriatric Nursing Assistants for over one year.
Failed to ensure anti-anxiety medication was destroyed after resident expired and narcotics were included in shift counts.
Medication error rate exceeded 5% due to crushing medications on Do Not Crush list and failure to take blood pressure prior to administration.
Failed to adequately train Geriatric Nursing Assistants serving as dietary personnel during meal services.
Failed to ensure resident was served therapeutic diet as prescribed by physician; resident served regular diet instead of puree diet.
Failed to maintain resident's physician assessment as part of medical record; initial assessment missing from record.
Failed to maintain proper infection control and sanitation procedures and promote resident dignity during feeding assistance.
Failed to ensure batteries for electronic lifts were charged and available and failed to document preventative maintenance.
Report Facts
Medication opportunities for error: 28
Medication errors: 3
Residents reviewed for care planning: 25
Residents reviewed for abuse: 3
Residents reviewed for hospitalization notice: 2
Residents reviewed for MDS accuracy: 6
Residents reviewed for medication communication: 9
Employee files reviewed for new hire competencies: 4
Employee files reviewed for annual evaluations: 2
Medication remaining: 29.75
Residents observed during medication pass: 3
GNA staff observed serving meals without training: GNA staff assigned to hot cart serving meals without documented training.
Residents reviewed for therapeutic diet: 14
Residents reviewed for medical record completeness: 25
Residents observed for infection control: 1
Electronic lifts and sit-to-stand devices inventory: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #4 | Geriatric Nursing Assistant | Failed to wash hands and fed resident without promoting dignity. |
| Staff #21 | Nurse | Made aware of feeding assistance concerns. |
| Director of Nursing | Director of Nursing | Acknowledged multiple deficiencies including abuse investigation and infection control. |
| Staff #13 | Nurse | Crushed medications on Do Not Crush list and failed to take blood pressure prior to medication. |
| Staff #14 | Geriatric Nursing Assistant | Unaware of resident diet change and served regular diet instead of puree. |
| Staff #11 | Facility Staff | Acknowledged inaccuracies in Minimum Data Set assessments. |
| Staff #12 | Nurse | Reviewed neurology consultation and communicated medication orders. |
| Nurse Educator #8 | Nurse Educator | Reported on new hire competency assessments. |
| GNA #20 | Geriatric Nursing Assistant | Lacked documented new hire skills assessment. |
| GNA #17 | Geriatric Nursing Assistant | Lacked documented new hire skills assessment. |
| GNA #16 | Geriatric Nursing Assistant | Lacked recent annual performance evaluation. |
| GNA #14 | Geriatric Nursing Assistant | Lacked recent annual performance evaluation and unaware of diet change. |
| Staff #3 | Dietary Manager | Unable to provide documentation of dietary training for GNA staff serving meals. |
| Staff #8 | Infection Preventionist | Reported staff without flu shot required to wear mask during meal service. |
| Maintenance Director #9 | Maintenance Director | Reported monthly checks of lifts but lacked documentation. |
Inspection Report
Routine
Deficiencies: 8
Date: Nov 3, 2017
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication usage, care planning, food safety, infection control, equipment maintenance, and clinical record keeping at Autumn Lake Healthcare at Chesapeake Woods.
Findings
The facility was found to have multiple deficiencies including inaccurate medication assessments on the Minimum Data Set (MDS), failure to complete required assessments such as the Abnormal Involuntary Movement Scale (AIMS), ineffective systems for reviewing psychiatric recommendations and transferring physician orders, failure to ensure drug regimens were free from unnecessary drugs, unsafe food storage practices, incomplete tuberculosis screening, malfunctioning walk-in freezer equipment, and incomplete clinical records.
Deficiencies (8)
Failed to accurately assess a resident's medication usage on the Minimum Data Set (MDS) assessment, including errors in documenting pain, anti-anxiety, and antibiotic medication usage.
Failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment as required by the resident's care plan for psychotropic drug use.
Failed to have an effective system to ensure psychiatric provider recommendations were reviewed by the physician, to transfer physician treatment orders month to month, and to monitor wandering behaviors.
Failed to ensure a resident's drug regimen was free from unnecessary drugs, including delayed implementation of pharmacy dose reduction recommendations and failure to document need for as needed anxiety and pain medications.
Failed to ensure food items were stored in accordance with professional standards for food safety, including uncovered spoiled vegetables and mislabeled dry storage containers.
Failed to have an effective system to ensure residents received the two-step tuberculosis screening test after admission.
Failed to ensure the walk-in freezer was maintained in good working order, with ice buildup and delayed repairs to door seals and vents.
Failed to maintain complete and accurate medical records, including missing documentation of device checks and failure to reconcile physician orders and treatment administration records.
Report Facts
Residents reviewed for medication usage: 5
Residents reviewed for TB screening: 3
Residents reviewed for clinical records: 3
Residents reviewed for wandering behavior monitoring: 32
Date of survey completion: Nov 3, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding medication assessment errors, AIMS assessment, psychiatric recommendations, TB screening, and clinical record keeping |
| MDS Nurse #6 | MDS Nurse | Confirmed errors in MDS medication assessment |
| Unit Nurse Manager | Unit Nurse Manager | Participated in psychotropic medication use evaluation and discussed psychiatric evaluation report availability |
| Certified Dietary Manager | Certified Dietary Manager | Observed food storage deficiencies and walk-in freezer condition |
| Maintenance Director | Maintenance Director | Provided service order invoices and information on freezer repairs |
| Infection Control Nurse | Infection Control Nurse | Reported on TB screening procedures and auditing |
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