Inspection Reports for
Chesapeake Place

The inspection identified multiple violations related to resident records, staff certifications, medication management, emergency preparedness, and documentation of resident rights and responsibilities. The facility was found non-compliant with several regulatory standards and was issued a violation notice with opportunities to submit plans of correction.

The complaint was substantiated. It involved allegations related to Resident Care and Related Services, including an incident where Resident #1 was pushed by Resident #2 in the dining hall, confirmed by interviews and staff reports.

The investigation supported the allegations of non-compliance with standards and laws, resulting in violations issued. The facility failed to ensure prior sex offender registry checks before admission and did not assume general responsibility for residents' health, safety, and well-being, including an incident where one resident was pushed by another.

Complaint was substantiated as the evidence gathered supported the allegations of non-compliance related to Resident Care and Related Services.

The investigation supported the allegations of non-compliance with standards or law, resulting in violations being issued. Specifically, the facility failed to ensure that an annual tuberculosis risk assessment was completed for each resident.

The visit was complaint-related, but the specific violation cited was not complaint related. The complaint substantiation status is not explicitly stated.

The facility was found to have a violation for not ensuring that a risk assessment for tuberculosis was completed annually on each resident, specifically Resident #3's record lacked the required annual tuberculosis evaluation.

Complaint related to Resident Care and Related Services was substantiated. Evidence included review of resident records, staff confirmation, and resident interviews confirming incidents.

The investigation supported the allegations of non-compliance with standards and laws, resulting in violations issued. Specific deficiencies included failure to perform a Sex Offender Registry check prior to admission and failure to ensure general responsibility for resident health and safety, including an incident where a resident was pushed by another resident.

The complaint was substantiated based on evidence including call bell logs showing assistance requests from resident #1 went unanswered for over an hour on two occasions on April 15, 2025, and confirmation by staff #1 that assistance was requested.

The investigation supported the allegations of non-compliance with standards or law, resulting in violations being issued. Specifically, the facility failed to regularly observe a resident for changes in physical, mental, emotional, and social functioning, and did not provide appropriate assistance when observation revealed unmet needs.

Complaint related to heating system malfunction; substantiated by evidence including use of space heater and Fire Marshall removal of heater.

The investigation confirmed non-compliance related to the heating system malfunction in a resident's room, where a space heater was used without approval from the Fire Marshall. Violations were issued and a plan of correction was submitted.

The complaint was substantiated as the evidence gathered supported the allegations of non-compliance related to staffing and supervision. The facility had not employed a new administrator or appointed a qualified acting administrator as of 12/16/2024, causing a lapse in administrator coverage.

The investigation supported the allegations of non-compliance with standards or law, resulting in violations issued. Specifically, the facility failed to immediately employ a new administrator or appoint a qualified acting administrator, causing a lapse in administrator coverage.

The complaint investigation was substantiated, with violations issued based on evidence gathered during the inspection.

The investigation supported the allegations of non-compliance with standards or law, resulting in violations issued. Deficiencies were found in areas including appropriateness of continued residence in the special care unit, annual tuberculosis risk assessments, completion and signing of Uniform Assessment Instruments (UAI), review and update of Individualized Service Plans (ISP), and maintenance of hot water temperatures within required ranges.

The complaint was substantiated as the evidence gathered supported the allegations of non-compliance with medication administration documentation standards.

The investigation found non-compliance with medication administration record keeping, specifically that the MARs for multiple residents did not indicate whether medications were administered or omitted, resulting in violations issued to the facility.

The inspection identified multiple violations related to resident record reviews, medication administration, staff certifications, tuberculosis screenings, assessment updates, care planning, resident rights postings, medication management including expired medications, staff authorization for medication administration, and emergency preparedness plan reviews.

Complaint received on 2024-05-20 regarding Safe and Secure Environment; evidence did not support the allegation of non-compliance.

The investigation did not support the allegation of non-compliance related to the complaint; however, a separate violation was identified concerning the failure to ensure tuberculosis screening documentation for staff prior to their first day of work.

Complaint investigation was initiated based on allegations received on 03/22/2024 and 03/25/2024. The evidence supported some allegations related to Resident Care and Related Services, Safe Secure Environment, and Buildings and Grounds. A violation notice was issued.

The investigation supported some but not all allegations, identifying non-compliance in Resident Care and Related Services, The Safe Secure Environment, and Buildings and Grounds. Several violations were cited including inadequate staffing in the safe, secure unit, incomplete Uniform Assessment Instruments, unsigned individualized service plans, and a non-functioning signaling device.

The complaint investigation was substantiated in part, with violations found related to Resident Care and Related Services, Buildings and Grounds, and the Safe Secure Environment. The complaint was received on January 17, February 15, and February 21, 2024.

The investigation supported some but not all allegations, identifying areas of non-compliance in Resident Care and Related Services, Buildings and Grounds, and the Safe Secure Environment. A violation notice was issued with deficiencies related to staffing, physical exam documentation, individualized service plans, personal assistance with bathing, and documentation of staff rounds.

The investigation supported the self-report of non-compliance with multiple standards, resulting in violation notices issued for failures including unsecured doors and windows in the memory care unit, lack of required physical examinations prior to admission, inadequate supervision of residents, and failure to document required resident checks.

The inspection identified multiple violations related to staff training, tuberculosis risk assessments, first aid certification, posting of the on-site manager, resident admission and discharge documentation, healthcare oversight, annual review of resident rights, and fire and emergency evacuation drills. Plans of correction were proposed for all deficiencies.

Complaint related: Yes. The complaint was substantiated in part regarding Resident Care and Related Services.

The investigation supported some of the allegations related to Resident Care and Related Services, resulting in a violation notice. Deficiencies were found in the completion of Uniform Assessment Instruments (UAI) prior to admission and annually, and in the annual review and update of Individualized Service Plans (ISP).

The investigation supported some, but not all, of the self-reported non-compliance related to Personnel. A violation notice was issued for failure to ensure staff were considerate and respectful of residents' rights and dignity.

The complaint was substantiated in part, with violations found in Personnel, Resident Care and Related Services, and Safe, Secure Unit. Some allegations were not supported.

The investigation supported some, but not all, allegations of non-compliance in the areas of Personnel, Resident Care and Related Services, and Safe, Secure Unit. Violations were found related to staffing levels, unsecured doors in the safe unit, failure to post current license, failure to report major incidents timely, and failure to report suspected abuse.

The complaint investigation was substantiated with violations issued. The complaint was related to administration, resident care, and related services. The final exit was conducted on August 8, 2022.

The investigation supported the allegation of non-compliance with standards and laws, resulting in violations issued. Specific deficiencies included failure to report major incidents within 24 hours, incomplete tuberculosis screening documentation prior to admission, and failure to update fall risk ratings after resident falls.

The inspection found multiple violations including missing sworn disclosure statements in staff records, outdated or missing CPR/first aid certification listings, inadequate staffing for medication administration on certain shifts, incomplete resident risk assessments and individualized service plans, missing signatures on required documents, improper use of physical restraints without physician orders, incomplete fire drill documentation, and missing criminal history reports within required timeframes.

Complaint related: Yes. The complaint involved the facility's freezer and stove not working, with the stove remaining non-operational during the inspection. Evidence included staff and resident interviews and documentation of repair attempts.

The investigation supported the allegations of non-compliance with standards related to kitchen equipment maintenance, specifically the facility stove/oven being non-operational during the inspection period. Violations were issued accordingly.

The complaint was received on 2021-10-25. The allegation that a resident was held without proper diagnosis and labeled as a 'prisoner' was determined to be not valid.

The investigation did not support the allegation that the resident was held without proper diagnosis and found the 'prisoner' claim to be invalid. However, other violations were cited related to the individualized service plans not including all assessed needs for residents.

The complaint was substantiated as valid based on evidence gathered from resident records, staff and resident interviews, and observations related to staffing adequacy and telephone system failures.

The facility failed to ensure adequate staffing with sufficient knowledge and numbers to provide necessary resident services, failed to post current on-site person in charge conspicuously, and had telephone system failures impacting communication. These deficiencies were supported by resident interviews, staff interviews, observations, and document reviews.

The facility failed to ensure the individualized service plan (ISP) was updated as needed for a significant change in a resident's condition, specifically for Resident #5 whose therapy services were not documented on the ISP.

The inspection identified multiple non-compliances including inadequate staff training in cognitive impairment and infection control, incomplete staff records such as missing sworn disclosure statements and tuberculosis screenings, insufficient staffing levels, incomplete or unsigned resident individualized service plans, medication management deficiencies, building maintenance issues, and failure to conduct required fire drills and criminal background checks timely.

The complaint investigation was initiated based on allegations in Staffing and Supervision, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, and Buildings and Grounds. The investigation did not substantiate the allegations.

The evidence gathered did not support the allegations of non-compliance with standards or law related to the complaints. However, violations unrelated to the complaints were identified, including failure to ensure medications were discontinued only with valid physician orders, failure to administer medications according to physician instructions, and failure to include initials of direct care staff on Medication Administration Records.

The inspection found multiple violations related to staff training, certification, medication management, individualized service plans, treatment plans for psychotropic medications, physical examination documentation, hospice care coordination, oxygen therapy orders, and criminal history record checks for new hires.

The inspection was complaint-related, initiated due to allegations concerning resident care and related services. The evidence supported non-compliance with standards or law, resulting in violations issued.

The investigation found multiple violations related to failure to ensure treatment plans for psychotropic medications, incomplete uniform assessment instruments, inadequate individualized service plans, lack of coordinated hospice care plans, and missing physician orders for oxygen therapy. Violations were issued based on these findings.

Complaint related: Yes. The complaint was regarding Resident Care and Related Services, Staffing and Supervision, and Buildings and Grounds. The evidence gathered supported the allegations and violations were issued.

The investigation supported allegations of non-compliance with standards or law, resulting in multiple violations related to failure to observe and document changes in resident condition, failure to implement medication management plans to avoid missed dosages, failure to administer medications according to physician orders, and failure to ensure Medication Administration Records included staff initials.

The complaint was related to staffing, resident care, medication, and medication administration. The evidence supported the allegations of non-compliance, resulting in violations issued.

The investigation found multiple violations including failure to maintain staff schedules for two years, medications administered outside the allowed time frames, medications not administered according to physician's orders, and missing initials of staff on Medication Administration Records. Violations were substantiated and corrective plans were outlined.

The facility was found to be non-compliant with applicable standards or law due to failure to ensure the interior of all buildings were kept clean, with multiple stains and scuff marks observed in both the Assisted Living Building and the Special Care Unit Building.