The Chesapeake

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF732Dec 4, 2025

  Based on observations, staff interview, resident interviews and facility documentation, the facility staff failed to ensure staffing information was posted on one of one unit in a prominent place and readily accessible to all residents, staff and visitors. The findings included:During the initial tour of the facility on 12/2/2025, there was no observation of the daily posting of the nurse staffing information on the nursing unit. On the second day of survey (12/3/2025), no nurse staffing information was observed on the unit. On 12/3/2025 during a medication pass and pour observation, an interview was conducted with an alert resident who stated he did not know how to determine how many staff members were working.On 12/3/2025 at approximately 12:40 p.m. […]

• No harm, potential for more than minimal, patternF574Dec 4, 2025

  Based on observation, resident interview, staff interview, and facility documentation, the facility's staff failed to ensure residents were aware of their right to contact the Ombudsman to advocate for them and of their right to file a complaint with the state certification agency. The findings included:On 12/03/25, during the group resident interview, none of the five residents (#2, #11, #21, #31, #43), that attended were aware of what or who the Ombudsman was or how to contact them. Also, none of the five residents in attendance were aware that they could make a complaint with the state agency or where they could find the information to do so. An interview was conducted with the facility's Activities Director (AD) and the Administrator on 12/03/25, at approximately 4:00 PM. […]

• No harm, potential for more than minimal, patternF577Dec 4, 2025

  Based on observations and interviews, the facility staff failed to ensure the survey results book was readily accessible to residents, family members and legal representatives of residents. The findings included:On 12/02/25 at approximately 2:00 PM., during the facility tour, in the main hall leading to the Health Center Unit a sign was observed on the bulletin board that read Survey Book is available upon request in the main office. On 12/03/25, an interview was conducted with the Administrator concerning the survey book accessibility. The administrator stated that they initially had the survey book available to everyone without needing to request access, but it was moved to the office during construction. […]

• No harm, potential for more than minimal, patternF585Dec 4, 2025

  Based on observation, resident interview, staff interview, and facility documentation, the facility's staff failed to ensure residents were aware of how to file a grievance or complaint. The findings included:On 12/03/25, during the group resident interview, none of the five residents (#2, #11, #21, #31, #43), that attended, were aware of the availability, or how to file a grievance or complaint. An interview was conducted with the facility's Activities Director (AD) and the Administrator on 12/03/25, at approximately 4:00 PM. The Administrator stated that Resident Rights, including how to file a grievance or complaint, are addressed on admission and discussed in Resident Council Meetings and in the Resident Handbook. […]

• No harm, potential for more than minimal, patternF695Dec 4, 2025

  Based on observation, interview, clinical record review and facility documentation the facility staff failed to provide respiratory care consistent with professional standards of practice for 3 Residents (#19, #1 and #42) in a survey sample of 24 Residents. The findings included:1. The facility staff failed to ensure oxygen nasal canula and concentrator tubing were changed according to the physician's order for Resident #19. Resident #19 was admitted to the facility originally on 06/22/2022 and most recently readmitted on [DATE]. On 12/02/2025 at 01:15 PM, an observation was made of Resident #19's oxygen nasal canula and concentrator tubing dated 11/23/2025; the humidification bottle attached to the oxygen concentrator was not dated. […]