Autumn Lake Healthcare at Chesapeake Woods

In the surveyor’s words

From the most serious findings on record at Autumn Lake Healthcare at Chesapeake Woods, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 19, 2025

  Based on record review and interviews it was determined that the facility staff failed to supervise a cognately impaired resident who was at high risk for elopement as evidenced by the resident leaving the facility unattended without the staff's knowledge. This deficient practice was evidenced in 1(#40) of 1 resident investigations reviewed for elopement during the recertification survey.The BIMS (Brief Interview for Mental Status) assessment is a quick standardized cognitive screening tool used in long-term care facilities to gauge a resident's orientation, attention and memory recall through simple questions about the date and repeating three words. […]

• Actual harm, isolatedF697Dec 2, 2021

  Based on the review of a medical record, the review of pertinent facility documentation, and interviews with facility staff, it was determined that the facility failed to initiate pain management as ordered. This was evident for 1 of 3 residents (Resident #5) reviewed for fractures during a complaint survey. The findings include: On 12/1/2021 at 1:00 PM a review of the facility's investigation related to an injury of unknown origin for Resident #5 revealed that on 8/30/2021 at 12:00 AM, a geriatric nursing assistant (GNA), Staff # 12 reported to the night shift nurse, LPN # 11, that Resident #5 vomited a large amount of brown liquid. […]

• No harm, potential for more than minimal, widespreadF812Dec 19, 2025

  Number of residents sampled: Number of residents cited: Based on observations, record review, and interviews with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the initial tour of the kitchen.The findings include:Cross-contamination refers to the transference of harmful substances or pathogenic microorganisms to food by hands, food contact surfaces, sponges, cloth towels, or utensils that have not been properly cleaned after contacting raw food and then touching ready-to-eat foods. […]

• No harm, potential for more than minimal, widespreadF923Dec 19, 2025

  Number of residents sampled: Number of residents cited: Based on observations and interviews with facility staff, it was determined that the facility failed to maintain clean and effective ventilation systems, thereby impeding proper airflow throughout the premises. This was evident in 13 out of 16 ventilation systems reviewed during the annual survey.The findings include:Local Exhaust Ventilation ([NAME]) systems are designed/engineered to capture and remove contaminants such as excessive heat, steam, condensation, vapor, smoke, and fumes. This is achieved by calibrating the total pressure, which is determined by the sum of the static pressure exiting and entering the system, minus the velocity pressure entering the system. […]

• No harm, potential for more than minimal, patternF558Dec 19, 2025

  Based on observations and interview it was determined that the facility staff failed to ensure residents had access to their calls bells if assistance was needed. This deficient practice was evidenced in 7 (#10, #28, #44, #59, #72, #83, & #85) out of 36 residents who resided on Choptank during the recertification survey.The findings include:On 12/10/25 at 7:44 am during observation rounds the surveyor observed multiple residents on the unit Choptank who did not have access to their call bells. At 7:46 am the surveyor observed Resident # 44 call bell on top of the fall mat next to the bed. At 7:53 am the surveyor observed Resident #85 & Resident #28 call bells on the floor. At 7:55 am the surveyor observed Resident #10 call bell hanging off the side of the bed. […]