Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Chesapeake Woods during CMS and state inspections, most recent first.
Staff did not obtain statements from all personnel present during the periods when two residents' alleged abuse incidents occurred. In both cases, several staff members who worked during the relevant times were not interviewed, as confirmed by the Administrator during the survey.
The facility failed to provide a homelike environment, as evidenced by damaged walls above sinks in multiple rooms on the Choptank Unit. The Corporate Maintenance Director confirmed the damage was due to water splashing, and the Administrator and DON were aware and indicated that repairs were in progress.
Facility staff failed to inform a resident's responsible party (RP) of changes in the medical regimen, including the administration of Seroquel, Haldol, and Depakote. The DON confirmed the RP was not notified as required by policy, and the involved nurses no longer work at the facility.
Facility staff failed to inform a resident's responsible party of a fall. The resident reported the fall to their cardiologist, who assessed for injuries and ordered an x-ray. The clinical record review revealed that the responsible party was not notified.
A resident reported an incident where a GNA laughed and left without providing requested incontinence care. The facility's investigation confirmed the abuse allegation, and the staff member was terminated after admitting to not assisting the resident due to having a bad day.
The facility failed to immediately report an allegation of verbal abuse made by a resident. The DON and AIT were unaware of the allegation, which was reported by a staff member but not addressed. The abuse was only reported to the Office of Health Care Quality after a follow-up interview with the DON.
The facility failed to conduct thorough investigations and maintain proper documentation for two residents. One resident's fall investigation lacked mandatory staff interviews, and another resident's abuse allegation investigation was incomplete, missing interviews and essential personnel file documentation.
The facility failed to ensure a physician sent a death certificate to the appropriate funeral home and did not provide adequate supervision for a resident with significant weight loss. A resident died, and the funeral home did not receive the death certificate, while another resident experienced a 9.75% weight loss over three months without the physician or PA-C addressing it in their progress notes.
The facility failed to accurately document wound assessments for a resident with a stage 3 pressure ulcer. Inconsistencies in the MDS assessments were found, which hindered proper monitoring of the wound's progression. The inaccuracies occurred when the regular MDS Coordinator was on leave, and a corporate MDS nurse was filling in.
The facility did not conduct a care plan meeting with an interdisciplinary team for a resident at the time of the Minimum Data Set (MDS) assessment. The scheduled care plan meeting was missed due to the absence of documentation and notes. Although the Social Worker notified the resident about the meeting through a letter, there was no follow-up documentation by the Unit Manager or nurse. Interviews revealed that the resident had not attended a recent care plan meeting, and the Social Worker was on leave during the scheduled session.
The facility failed to provide appropriate respiratory care for a resident with emphysema and COPD by not recording pulse oximeter readings on several dates, despite an order for oxygen therapy and monitoring. The DON confirmed that these readings were necessary to evaluate the resident's oxygen saturation levels.
The facility failed to ensure that a resident's medication irregularity report was reviewed by the primary care physician and that the recommendations were addressed in a timely manner. The reports did not contain the required physician's acknowledgment or action taken, as confirmed by the DON.
The facility staff failed to ensure a resident's medication regimen was free from unnecessary drugs, as the resident was prescribed two vitamin D3 medications. Despite the pharmacist's recommendation to evaluate and possibly discontinue one, no action was taken until prompted by the surveyor. The DON acknowledged the oversight.
The facility failed to limit an as-needed psychotropic medication, alprazolam, from being prescribed for less than 14 days for a resident. Despite recommendations from the pharmacy to discontinue the medication, it remained active for over 30 days. The DON acknowledged the lack of action taken to address the pharmacy's irregularity reports.
The facility failed to store medications appropriately, with an LPN dispensing medication from blister packs with varying expiration dates and another LPN identifying a medication dosage discrepancy before administration. Additionally, a medication cart was found unattended and unlocked, highlighting lapses in medication storage and security protocols.
The facility failed to ensure staff performed hand hygiene as per policy, with two staff members observed not sanitizing hands between tasks and providing incorrect information about the hand hygiene policy.
The facility staff failed to provide consistent ADL care for two residents, resulting in missed showers and inadequate documentation. One resident did not receive showers as per their care plan, and another went several days without a shower, with inconsistencies in the shower schedule and documentation.
The facility encountered issues with maintaining medical records and safeguarding resident-identifiable information. An unattended computer screen displaying a resident's medication profile was left visible on a medication cart in the hallway. Incorrect patient information was scanned into another resident's electronic medical record, causing discrepancies. Additionally, a resident's substitute decision maker was incorrectly identified without proper documentation, and the resident's profile was not updated upon admission. Inconsistent documentation was also found in a skin evaluation, where an open skin area was noted by one nurse but not identified in a subsequent weekly evaluation.
Failure to Interview All Relevant Staff During Abuse Investigations
Penalty
Summary
Facility staff failed to conduct thorough investigations into allegations of abuse involving two residents. In one case, twenty-one different staff members worked on the unit during the timeframe when an alleged incident may have occurred, but statements were not obtained from all staff present during that period. In another case, not all staff who worked during the time a resident's bruise was discovered were interviewed, including a CMA, GNA, and a female staff member. The Administrator confirmed that some staff, such as a GNA and dining room attendant, were not interviewed as part of the investigation. These omissions were identified through record review and staff interviews during the recertification survey.
Failure to Provide Homelike Environment
Penalty
Summary
The facility failed to provide residents with a homelike environment, as evidenced by damaged walls above the sinks in multiple rooms on the Choptank Unit. During the initial screening, the surveyor observed the damage in rooms 73, 75, 80, 83, 84, 85, 87, and 89. The Corporate Maintenance Director was informed of the issue and confirmed that the damage was due to water splashing. The Administrator and Director of Nursing were aware of the damaged walls and indicated that repairs were in progress.
Failure to Inform Responsible Party of Medication Changes
Penalty
Summary
The facility staff failed to ensure a resident's responsible party (RP) was informed of a change in the medical regimen. This was evident for one resident out of 53 surveyed. The resident's primary physician prescribed Seroquel, Haldol, and Depakote on different dates, but the RP was not informed of these medications being ordered and administered. The Director of Nursing (DON) confirmed that the RP was not notified as required by the facility's policy. The DON reviewed the electronic health record and the hard chart but could not find documentation that the RP was informed, except for the Depakote order. The nurses involved in these changes no longer work at the nursing home.
Failure to Notify Responsible Party of Resident's Fall
Penalty
Summary
The facility staff failed to ensure a resident's responsible party (RP) was informed of a fall. This deficiency was identified during an investigation into intake #MD00178237, which revealed that a resident had a fall in April 2022. The resident informed their cardiologist about the fall a couple of nights later. The cardiologist assessed the resident for signs of injury and noted complaints of left side pain along the ribcage. An x-ray was ordered and obtained the next day. However, the clinical record review showed that the resident's RP was not notified of the fall.
Failure to Protect Resident from Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from abuse by a staff member. During an interview, the resident described an incident where a Geriatric Nursing Assistant (GNA) laughed at the resident and left the room without providing the requested assistance for an incontinent incident. The resident reported this incident to the facility, which led to an investigation. The facility's investigation report confirmed the abuse allegation, and the staff member was suspended pending the investigation's conclusion. The Director of Nursing (DON) conducted an interview with the staff member, who admitted to not assisting the resident due to having a bad day. The DON did not review the staff member's written statement before the interview, which contained discrepancies. The facility's investigation verified the abuse allegation, and the staff member was terminated. The incident was reported to the Office of Health Care Quality, and the facility took action based on the investigation's findings.
Failure to Immediately Report Allegation of Abuse
Penalty
Summary
The facility failed to immediately report an allegation of abuse to the State Office of Health Care Quality. During an annual and complaint survey, it was found that the facility did not report an allegation of verbal abuse made by a resident. The surveyor reviewed an investigation report and found that the resident had reported verbal abuse by aides during an interview conducted on 10/2/23. However, the Director of Nursing (DON) and the Administrator In Training (AIT) who conducted the investigation were unaware of this allegation. The DON stated that the allegation was reported by the staff member conducting the interviews but was not addressed at the time. The surveyor conducted interviews with the DON and Unit Manager, who both denied conducting the specific interview in question. The DON acknowledged that a review of the entire investigation should have been completed before submitting the follow-up investigation report. The allegation was only reported to the Office of Health Care Quality on 3/5/24, after the surveyor's follow-up interview with the DON. This delay in reporting the abuse allegation constitutes a failure to comply with the requirement to immediately report suspected abuse.
Incomplete Investigations and Documentation Failures
Penalty
Summary
The facility staff failed to ensure a thorough investigation and maintain documentation of the investigation for two residents. For Resident #88, the investigation into a fall incident revealed that the nurse conducting the investigation did not include staff interviews, which are mandatory to determine the cause and rule out abuse. The Director of Nursing (DON) confirmed that no staff interviews were present in the investigation folder and acknowledged past issues with investigations. Despite the checklist indicating that witness statements were reviewed, no such statements were found, and the DON could not explain the discrepancy. For Resident #90, the facility's investigation into an allegation of physical abuse by a Geriatric Nursing Assistant (GNA) was incomplete. The resident reported being grabbed and shoved by the GNA, and a subsequent skin assessment revealed a bruise on the resident's wrist. The DON substantiated the abuse based on the resident's account and the bruise but did not conduct interviews with the accused staff member, other staff on the unit, or other residents who received care from the GNA. Additionally, the personnel file for the GNA lacked evidence of a completed criminal background check, abuse/neglect training, and license verification. The DON confirmed that the investigation file was complete despite these omissions.
Failure to Send Death Certificate and Address Significant Weight Loss
Penalty
Summary
The facility staff failed to ensure that a physician sent a death certificate to the appropriate funeral home and failed to provide adequate supervision for a resident experiencing significant weight loss. In the first case, Resident #337 died, and the funeral home handling the funeral did not receive the death certificate. Staff #21 was unaware of the missing death certificate until contacted by the second funeral home, and there was no evidence that the physician sent the death certificate to either funeral home involved. This oversight was confirmed through staff interviews and clinical record reviews, indicating a lapse in the facility's protocol for handling death certificates. In the second case, Resident #96 experienced a significant weight loss of 9.75% over three months, which was not addressed by the physician or the Physician Assistant, Certified (PA-C) in their progress notes. Despite weight change alerts being noted in the electronic record, the physician's and PA-C's notes did not reflect any weight changes. The Director of Nursing (DON) acknowledged the concern and noted that although the facility Dietician documented the weight changes and implemented dietary changes, the lack of physician supervision was a significant issue. This deficiency highlights a failure in monitoring and addressing significant weight loss in residents, as required by CMS guidelines.
Inaccurate Documentation of Wound Assessments
Penalty
Summary
The facility failed to accurately document wound assessments in a resident's medical record, specifically for a resident with a stage 3 pressure ulcer. The wound note from the Wound Nurse Practitioner indicated that the resident had a stage 3 pressure ulcer, but the Minimum Data Set (MDS) assessments were inconsistent. One assessment documented the presence of a pressure ulcer but did not stage it, while another assessment incorrectly documented that the resident did not have a pressure ulcer. These inconsistencies hinder the facility's ability to monitor the progression of the wound accurately. Interviews with the MDS Coordinator and the Director of Nursing revealed that the inaccuracies occurred when the regular MDS Coordinator was on leave, and a corporate MDS nurse was filling in. The Director of Nursing confirmed that the coding for the resident's pressure ulcer was incorrect during this period. The MDS Coordinator stated that she reviews the wound care team's documentation when coding pressure ulcers and acknowledged that the current MDS wound assessment for the resident is accurate.
Missed Interdisciplinary Care Plan Meeting for Resident During MDS Assessment
Penalty
Summary
The deficiency identified in the report pertains to the facility's failure to conduct care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. Specifically, for Resident #17, it was found that the care plan meeting scheduled for 12/21/23 was missed, as evidenced by the absence of documentation and notes from the meeting. Despite efforts made by the Social Worker to notify the resident about the meeting through a letter, the lack of follow-up documentation by the Unit Manager or nurse led to the oversight. During interviews with Resident #17 and facility staff, it was revealed that Resident #17 had not attended a care plan meeting recently, and the Social Worker responsible for organizing the meetings was on leave during the scheduled care plan session.
Failure to Document Pulse Oximeter Readings for Oxygen Therapy
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for oxygen administration for Resident #17. The resident had a care plan initiated for emphysema and COPD, which included an order for oxygen therapy at 4 liters via nasal cannula and pulse oximeter readings every shift to ensure oxygen saturation levels were greater than or equal to 90%. However, the pulse oximeter readings were not recorded on several dates in December 2023, despite oxygen being checked off as administered on all three shifts for those days. The facility's policy on oxygen administration required that the resident's care plan identify interventions for oxygen therapy and that monitoring of oxygen saturation levels be conducted as ordered. The Director of Nursing confirmed that the pulse oximeter readings should have been recorded and were necessary to evaluate if Resident #17's oxygen saturation was greater than 90%, as per the physician's order. This failure to document the pulse oximeter readings constituted a deficiency in providing appropriate respiratory care for the resident.
Failure to Address Medication Irregularities
Penalty
Summary
The facility failed to ensure that a resident's medication irregularity report was reviewed by the primary care physician and that the recommendations were addressed in a timely manner. This deficiency was identified for one resident who had multiple monthly medication regimen reviews (MRR) with comments and recommendations noted. However, the reports did not contain the required physician's acknowledgment of the irregularity or the action taken to address it. The Director of Nursing (DON) confirmed that the reports were not being kept in the designated binder and were missing the necessary documentation from the physician. The facility's policy on addressing medication regimen review irregularities requires that any irregularities noted by the pharmacist be documented and sent to the attending physician, medical director, and DON. The attending physician must then document in the resident's medical record that the irregularity has been reviewed and what action has been taken. In this case, the reports for the resident did not meet these requirements, leading to a failure in the process of addressing medication irregularities as per the facility's policy.
Failure to Address Unnecessary Medications
Penalty
Summary
The facility staff failed to ensure that a resident's medication regimen was free from unnecessary drugs. This was evident for one resident who was prescribed two vitamin D3 oral medications, one to be taken every 7 days and the other daily. The pharmacist recommended evaluating the necessity of both medications and considering discontinuation of one. Despite this recommendation, no action was taken until the surveyor's request, leading to the discontinuation of one of the medications. The Director of Nursing acknowledged the lack of action in addressing the pharmacy's irregularity reports.
Failure to Limit As-Needed Psychotropic Medication
Penalty
Summary
The facility failed to limit an as-needed psychotropic medication, alprazolam, from being prescribed for less than 14 days for Resident #17. The medication regimen review (MRR) irregularity report completed on 11/20/23 and 12/4/23 recommended a 14-day stop date and discontinuation of the medication, respectively. Despite these recommendations, the alprazolam order written on 11/1/23 remained active until 12/4/23, making the medication available as needed for over 30 days. The Director of Nursing (DON) acknowledged the lack of action taken to address the pharmacy's irregularity reports during an interview with the surveyor on 2/27/24.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to store medications appropriately according to standards of practice. During a medication administration observation, an LPN retrieved multiple blister packs of Allopurinol for a resident, with varying expiration dates, including one that had expired. The LPN ultimately dispensed the medication as prescribed. Additionally, another LPN was observed preparing medication for a different resident and found a discrepancy between the medication label and the resident's chart. The LPN identified the correct medication and dosage before administration. Interviews with staff revealed that Certified Medication Aides restock medications, but nurses are responsible for checking expiration dates and ensuring correct dosages before administration. The facility's Medication Storage Policy was requested but not provided by the time of the survey exit. In a separate incident, a medication cart was observed unattended and unlocked on the Chesapeake Unit. An LPN confirmed that the cart should not have been left unlocked and identified the responsible nurse, who admitted to leaving the cart unattended to get water. The Unit Manager stated that education on the expectation to lock medication carts when unattended would be initiated. These observations indicate lapses in medication storage and security protocols within the facility.
Failure to Perform Hand Hygiene
Penalty
Summary
The facility failed to ensure that staff performed hand hygiene as per the established policy. This deficiency was observed in two out of seven staff members. Specifically, a Geriatric Nursing Assistant (GNA) was seen serving breakfast, touching the resident environment, and then proceeding to the juice cart without performing hand hygiene. Another GNA was observed assisting a resident, touching the bed, and handling food without sanitizing hands between tasks. Both staff members provided incorrect information about the facility's hand hygiene policy when questioned by the surveyor. Additionally, a Certified Medication Aide/Geriatric Nursing Assistant (CMA/GNA) provided inconsistent information about the hand hygiene policy, indicating a lack of proper understanding among staff. The Choptank Unit Manager and the Director of Nursing acknowledged the missed hand hygiene opportunities and indicated plans to address the issue. However, the deficiency was evident during the surveyor's observations, highlighting a failure in adherence to infection prevention and control protocols.
Failure to Provide Consistent ADL Care
Penalty
Summary
The facility staff failed to provide activities of daily living (ADL) care in accordance with the residents' plans of care for two residents. Resident #188, admitted in June 2022, had a baseline care plan indicating a preference for showers. However, documentation reviewed for September 2022 showed that out of 39 opportunities for bathing, only 34 were documented, with no specific documentation of showers being given. The Director of Nursing (DON) confirmed that the shower schedule for Resident #188 was not triggered on the Kardex, and there was no documentation to confirm that showers were provided as per the resident's preference. Resident #17, who has a care plan initiated in November 2023 due to hemiplegia, reported not receiving showers consistently. The review of the shower log for January and February 2024 revealed inconsistencies in documentation, with Resident #17 going several days without a shower and no refusals documented. The DON acknowledged the discrepancies and stated that the updated shower schedule was not correctly entered, leading to missed showers. The DON also mentioned ongoing education about documentation and communication of showers.
Medical Record Maintenance and Resident Information Safeguarding Issues
Penalty
Summary
The facility failed to maintain medical records in accordance with acceptable professional standards and practices by not safeguarding resident-identifiable information and keeping accurate documentation for Residents #17, #21, and #188. In the case of Resident #17, the computer screen displaying the resident's medication profile was left unattended and visible to others on a medication cart in the hallway. LPN Staff #30, responsible for the cart, acknowledged the expectation to lock the screen when unattended but failed to do so. For Resident #21, a consult note with incorrect patient information was scanned into the electronic medical record, leading to discrepancies in the record. Additionally, for Resident #188, the facility incorrectly identified the resident's substitute decision maker without proper documentation and failed to update the resident's profile upon admission. Furthermore, in the case of Resident #188, inconsistent documentation was found regarding a skin evaluation, where a note by RN Staff #32 indicated an open skin area, but the weekly skin evaluation by Nurse #33 did not identify any concerns. The facility's policy required full body skin evaluations upon admission and weekly thereafter, highlighting the discrepancy in the documentation process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Cambridge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mallard Bay Nursing And Rehab | 0 mi | — | 21 | 0 |
| Pines Nursing And Rehab | 12.9 mi | — | 32 | 0 |
| Willowbrooke Ct Skilled Care Ctr At Bayleigh Chase | 13 mi | — | 0 | 0 |
| Solomons Nursing And Rehab Center | 25.2 mi | — | 1 | 0 |
| Caroline Nursing And Rehab | 25.4 mi | — | 5 | 0 |
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