Autumn Lake Healthcare at Chevy Chase

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF584Apr 28, 2025

  Based on observation and interview, it was determined that the facility failed to maintain a homelike environment for the residents as evidenced by failure to 1) keep the utility rooms, and resident shower room clean and organized; 3) ensure that residents were provided with hot water during the survey. This was evident during multiple observations made on the Arcadia Unit and throughout the facility. The findings include: 1) On 04/16/25 at 08:43 AM, an initial observation of the Arcadia unit in rooms [ROOM NUMBERS] revealed a toilet paper roll in the bathroom that was hung by a trash bag and tied around a handrail. […]

• No harm, potential for more than minimal, patternF657Apr 28, 2025

  Based on record reviews and interviews it was determined that facility staff failed to ensure that resident records were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. This deficient practice was evident for 3 (#66, #86, #101) residents out of 4 residents reviewed for care plan meetings and quarterly assessment during the facility survey. The findings include: 1.) On 04/16/25 at 10:41 AM, during an interview, Resident #66, reported that they have not participated in care plan meetings. […]

• No harm, potential for more than minimal, patternF658Apr 28, 2025

  Based on medical record review and interview with facility staff, it was determined that the facility failed to: 1) implement wound and skin care orders for a resident admitted after a surgical amputation and identified pressure ulcer; 2) provide services as order by the physician; and 3) maintain professional standards of practice when documenting a resident's showers. This was identified for 4 of 4 (#160, #106, #66, #108) residents reviewed for orders and documentation during the survey. The findings include: 1. Review of the medical record on 4/25/25 at 12:13 PM for Resident #160 revealed admission to the facility with diagnosis including aftercare following surgical amputation, gangrene and peripheral vascular disease. […]

• No harm, potential for more than minimal, isolatedF641Apr 3, 2026

  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 (#7) of 3 residents reviewed for pressure ulcers. The findings include Minimum Data Set- The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. On 3/31/26 at 1:11 PM, a review of Resident #7's medical record revealed Resident #7 was admitted to the facility in the beginning of January 2026 for rehab following an acute hospitalization. […]

• No harm, potential for more than minimal, isolatedF656Apr 3, 2026

  Based on medical record review and staff interview, it was determined that the facility staff failed to timely develop and implement a comprehensive, resident centered care plan for a resident admitted to the facility with preexisting pressure ulcers. This was evident for 1 (#7) of 3 residents reviewed for pressure ulcers. The findings include: The MDS (Minimum Data Set) is a federally mandated, comprehensive assessment tool to ensure each resident's 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. […]