Autumn Care of Chesapeake

In the surveyor’s words

From the most serious findings on record at Autumn Care of Chesapeake, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF919Dec 8, 2023

  Based on observation, Resident and staff interviews, and facility documentation review, the facility staff failed to maintain a Resident call system for Residents to call for staff assistance, on three of four nursing units. The findings included: On three of four nursing units, the facility staff failed to ensure that there was a Resident call system in the bathrooms and showers to allow Residents to call for staff assistance, if needed. On 12/5/23, during an initial tour of the facility it was noted that on three of the Resident care units, there was not a functional call bell system. The Residents were noted to have hand bells and/or tap bells at the bedside. There was no device noted in the Resident bathrooms, many of which also contained showers. […]

• No harm, potential for more than minimal, patternF554Dec 8, 2023

  Based on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to assess and determine if a Resident was safe to self-administer medications that were at the bedside, for six Residents (Resident #42, 54, 77, 51, 78 and #7) in a survey sample of 55 Residents. The findings included: 1. For Residents #42, 54, 77, 51, and 78, all of whom had medications stored in their room, the facility staff failed to assess if the Residents were safe to self-administer medications. On [DATE] at approximately 12:00 PM, observations were conducted of the 100 unit. Multiple Residents were noted to have over the counter medications at the bedside. They included: a. Resident #42 had hair growth pills/supplement at bedside. b. […]

• No harm, potential for more than minimal, patternF689Dec 8, 2023

  Based on observation, resident interview, staff interviews, facility documentation review and clinical record review, the facility staff failed to maintain a safe environment, free of accident hazards on one of four Resident care units. The findings included: On the one hundred nursing unit, the facility failed to secure medications and chemicals to maintain a safe environment, free of accident hazards. 1a. On [DATE] at approximately 12:00 PM, observations were conducted of the 100 unit. Multiple Residents were noted to have over the counter medications at the bedside. They included: a. Resident #42 had hair growth pills/supplement at bedside. b. Resident #54 had Nutririte-800 multivitamins on the bedside table. c. […]

• No harm, potential for more than minimal, patternF727Dec 8, 2023

  Based on review of the Payroll Based Journal (PBJ) Staffing Data Report, review of the actual working schedules for nurse staff, and staff interviews, the facility staff failed to ensure they had a Registered Nurse (RN) providing services at least eight consecutive hours within each twenty-four hour period, 7 days a week. The findings included: The Fiscal Year Quarter 4 2023 (July 1 - September 30) PBJ Staffing Data Report triggered for four or more days within the quarter with no RN hours. […]

• No harm, potential for more than minimal, patternF759Dec 8, 2023

  Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to ensure the medication error rate was less than 5%. There were 4 medication errors in 26 opportunities, affecting two (2) Residents (Resident #26 and #85), resulting in a 15.38% medication error rate. The findings included: On [DATE] at 8:16 AM, LPN #6 was observed to prepare and administer medications to Resident #26 & at 8:22 AM, administered medications to Resident #85. […]