Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 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.
Failure to supervise a cognitively impaired resident at high risk for elopement resulted in the resident leaving a locked dementia unit unattended. The resident had a BIMS score of 5/15 and had been identified as high risk to wander. The investigation found the secured unit door malfunctioned and was not locking properly, and the resident was found in a visitor's truck in the parking lot before being returned to the facility.
Kitchen sanitation and equipment maintenance deficiencies were observed throughout the facility. The surveyor found missing hand sinks near the ice machine, drink station, and mop sink area; unclean ice and dishwashing equipment; loose and unclean sinks; sanitizer above 400 ppm; gray water splashing onto the floor from sink drains; and multiple unclean or improperly maintained prep and cookline surfaces. Additional concerns included obstructed hood ventilation, unclean refrigeration and freezer conditions with heavy frost and food stored on the floor, and a non-commercial ice chest with standing water and black particles.
Ventilation systems were found to be ineffective in multiple areas after surveyors observed poor airflow in the kitchen and tested exhaust fans throughout the facility. The Type 2 hood above the dishwasher did not capture steam, and the Type 1 canopy hood over the convection oven and steamer allowed grease, steam, heat, condensation, and vapors to escape into the kitchen. Tissue-paper testing also showed several exhaust fans were inoperable in laundry, utility, closet, and bathroom areas.
Residents on the Choptank unit did not have consistent access to their call bells, with multiple call bells found on the floor, on a fall mat, hanging off the bed, inside a bedside drawer, or clipped to a privacy curtain. The surveyor observed this issue in several residents, and the DON and an RN unit manager stated staff should ensure residents have their call bells when entering rooms.
Soiled Waste Baskets and Stained Sinks Observed in Resident Rooms Surveyors observed multiple resident rooms with stained bathroom sinks, pink stains in a sink, stains on a bathroom floor, and soiled unlined waste baskets placed near a resident's wheelchair and near bed B. The EVS Director later stated that multiple trash cans had been found without bags during rounds and that waste bags were kept in the linen closet for staff use when EVS was not present.
Infection Control and Sanitation Deficiencies: Surveyors observed unlabeled resident personal care items in shared bathrooms, multiple hand hygiene failures by dietary and nursing-related staff, and unsanitary conditions in food service areas including standing water in an ice chest, wet nesting on dome plate covers, and improper handling of food carts and equipment. Additional findings included rusted commodes, a full urinal stored on a bedside dresser near resident food items, poor laundry room sanitation and ventilation, an oxygen tube left attached to a cylinder, and uncovered IV poles with visible dirt or spills.
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.
A facility failed to ensure residents whose funds were managed by the facility had ready and reasonable access to their money. The BOM stated residents had to request cash from front desk or business office staff, money had to be in the cash box or would be obtained by the next day, and after-hours/weekend access was limited to $5 or $10. Surveyors noted residents were supposed to have immediate access up to $100, or $50 for Medicaid residents, with amounts over that available within 3 days.
A resident was transferred to an acute care facility for a change in medical condition, but the record did not show written notice of the bed hold policy was given to the resident or resident representative. The Administrator stated the policy was mailed to the representative, but no written proof of notification or receipt was available.
Failure to develop person-centered care plans for wandering risk, oral hygiene needs, and ADL refusal. A resident assessed as high risk for elopement had no person-centered plan for that risk, and another resident who could not perform oral hygiene independently had a non-specific ADL plan that only said staff would set up teeth brushing, not that staff would brush the resident’s teeth. A third resident had missed showers with no documented reason, and the DON stated the resident refused showers, but no care plan for ADL refusal was provided.
Failure to document missed enteral nutrition for a resident with a TF order. The record showed multiple instances where the resident received zero tube feeding, and one entry indicated a note should exist but none was found in PCC. During observation, the TF pump was beeping, an LPN found air in the tubing, and the resident went without enteral nutrition for at least 30 to 45 minutes; the RN UM stated the physician should have been notified and a note written.
Missing Annual Performance Review for a GNA. Surveyors found that the facility did not complete an annual performance review for one GNA file reviewed. The DON confirmed there was no current performance evaluation available and acknowledged that GNA evaluations should be done annually.
A resident’s MMR showed a consulting pharmacist recommendation that the evening dose of Midodrine 5 mg be given no later than 6:00 PM, but the MAR still showed the dose being administered at 9:00 PM. Only one of two pharmacist recommendations was addressed, and an PA later confirmed the missed order had not been acted on.
Meals were found to be unpalatable, insufficiently portioned, and held at unsafe temperatures. A resident’s POA reported inadequate portions, another resident complained that the food had poor taste and texture, and staff were observed serving scrambled eggs without cheese to residents who had ordered eggs with cheese. Test tray temperatures were also recorded below the food danger zone, including several hot items and applesauce stored overnight on a pushcart at 57 degrees F.
A facility was cited for not being able to identify the governing body legally responsible for establishing and implementing policies for facility management and operations, or who was responsible for appointing the licensed administrator. During the QAPI process and an interview, staff could not explain who held this responsibility, and the Administrator stated she knew corporate leadership came to the building but was unsure who was legally responsible for the building and its leadership.
Essential kitchen equipment was not maintained in safe operating condition. A steam table at the cookline was observed inoperable, the Type 2 vent above the high-temp dishwasher did not adequately remove steam, and the walk-in freezer had excessive ice, frost, and icicles covering the unit and food items. The Administrator, Maintenance leadership, and HCSG leadership witnessed the observations, and the steam table was later still turned off and nonfunctional.
A resident seated in a wheelchair could not reach the call bell because it was positioned behind the wheelchair, and the resident stated that was where it was placed each morning. The surveyor also observed a restroom call bell cord in a room that was too short to be reached by a resident on the floor.
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 Supervise High-Risk Resident During Elopement
Penalty
Summary
Facility staff failed to supervise a cognitively impaired resident who was at high risk for elopement, resulting in the resident leaving the facility unattended without staff knowledge. Resident #40 was on the Dementia Unit Choptank, which was a locked unit, and had a BIMS score of 5/15 at the time of the incident. The resident had been identified on admission as high risk to wander on the Wandering/Elopement assessment completed on 05/12/23. The elopement occurred when a visitor in the parking lot heard the resident attempting to open the door to the visitor's truck and then brought the resident back to the facility. The investigation found that the secured door leading out of the Dementia Unit malfunctioned and was not securely locking. The Regional Director of Maintenance stated the plate that grabbed the mag lock would not close and had to be adjusted, and the Administrator reported staff checked the doors every shift for 4 days after the incident. The surveyor also found no documentation to verify the door was repaired prior to 02/26/25.
Kitchen sanitation and equipment maintenance deficiencies
Penalty
Summary
The facility failed to maintain food service equipment and kitchen areas in sanitary condition during the initial kitchen tour. The surveyor observed that the handwashing sink was missing near the ice machine and drink station, the ice machine was unclean, and the ice bucket and scoop were stored on top of the machine. In the mop sink and chemical storage area, a hand sink was also absent, the area was cluttered, and the mechanical exhaust ventilation could not be verified because of insufficient lighting. In the warewashing area, the hand sink and faucet were not securely fastened to the wall and sink basin, the high-temperature mechanical dishwasher was unclean inside and out, and steam from the dishwasher was observed dissipating into the kitchen instead of being drawn into the exhaust system. The 3-compartment sink had sanitizer measured above 400 ppm, the faucet was loose, the sealant around the sink was unclean and/or missing, and a dump test caused gray water to splash onto the kitchen floor. Standing gray water was also observed in cracked floor tiles around the floor sink. Additional observations in the food preparation, cooking, storage, and freezer areas showed multiple sanitation and maintenance problems. These included an unclean can opener, improperly hung utensils, a prep sink that discharged gray water onto the floor, unclean bulk food bins, makeshift painted wooden legs on a prep table, clean dish racks stored less than 18 inches above the floor, unclean cooking equipment under the canopy hood, an overshelf and protruding equipment obstructing exhaust, unclean hood baffles, an inoperable steam table, personal items near the cookline, unclean warming cabinet gaskets, unclean refrigerator gaskets and shelving, torn freezer gaskets, heavy frost and ice buildup in the walk-in freezer with sealed food boxes stored on the floor, and a non-commercial ice chest and 5-gallon water dispenser with standing water and black particles. The surveyor also noted water damage on the food storage area ceiling, improper storage of mixer attachments, and multiple structural and drainage issues throughout the kitchen.
Ventilation Systems Not Functioning Properly
Penalty
Summary
The facility failed to maintain clean and effective ventilation systems, and survey observations found that 13 of 16 ventilation systems reviewed during the annual survey were not functioning as intended. During kitchen observations, the surveyor used a smoke stick to assess airflow in the local exhaust ventilation systems and found that the Type 2 hood above the high-temperature mechanical dishwasher was inadequately designed and calibrated, with steam dissipating into the kitchen instead of being captured by the hood. The Type 1 canopy hood over the commercial convection oven and steamer was also positioned so the appliance extended beyond the hood overhang, allowing grease, steam, heat, condensation, and vapors to escape into the kitchen. Further physical verification of exhaust fan function was completed with the Regional Maintenance Director by placing tissue paper on exhaust fan covers. Multiple areas were found inoperable, including the dirty laundry room, clean laundry room, Choptank janitor's closet, soiled utility closet, one spa room, the B-wing soiled utility room, the B-wing janitor's closet, and several resident bathrooms. Some areas were noted as sufficient, including the E hallway bathroom, one spa room, and the oxygen tank storage room was noted as positive pressure. The Administrator was informed of the findings, and the Regional Maintenance Director had also shared the information.
Residents Lacked Access to Call Bells
Penalty
Summary
The facility failed to ensure residents had access to their call bells when assistance was needed on the Choptank unit, affecting 7 of 36 residents observed during the recertification survey. During observation rounds, the surveyor found multiple call bells out of reach or not readily accessible: one resident’s call bell was on top of the fall mat next to the bed, two residents’ call bells were on the floor, one resident’s call bell was hanging off the side of the bed, one resident’s call bell could not initially be located and was later found inside the top drawer of the bedside table by a GNA, one resident’s call bell was on the floor near the head of the bed close to the wheel, and one resident’s call bell was clipped to the privacy curtain. On a later observation, the surveyor again reported several residents without access to their call bells. The DON stated that whenever staff go into a resident’s room, they are to ensure the resident has their call bell, and the RN Unit Manager stated staff should ensure residents have their call bells as much as possible.
Soiled Waste Baskets and Stained Sinks in Resident Rooms
Penalty
Summary
Facility staff failed to provide a clean, homelike environment in resident rooms on the Unit Choptank, as surveyors observed multiple environmental cleanliness issues during the recertification survey. In several rooms, the surveyor noted stained sinks in resident bathrooms, soiled and unlined waste baskets placed next to a resident's wheelchair and near bed B, pink stains in a sink, and stains on a bathroom floor. The observations were made during room-by-room rounds, and the environmental concerns were later discussed with the EVS Director, who stated that multiple trash cans had been found without bags during rounds and that waste bags were kept in the linen closet for staff use when EVS was not present.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to provide an infection prevention and control program that maintained a safe, sanitary, and comfortable environment to minimize cross-contamination. During observation rounds, the surveyor found that residents’ personal care items in shared bathrooms were not labeled in multiple rooms on the Choptank unit. The Director of Nursing later acknowledged that staff had been made aware to label residents’ personal care items. The surveyor also observed multiple hand hygiene and sanitation concerns in food service and resident care areas. Employees entering the kitchen area had to walk across the kitchen to reach available hand sinks after donning hairnets, and the HCSG Regional Manager confirmed there was no hand sink by the front entrance. The surveyor observed ice and water service equipment positioned near the kitchen and nurses’ station without nearby open sinks for handwashing, and found standing melted ice water with floating black particles inside an ice chest. Dietary staff stated they did not wash their hands before or after glove use while serving food and said they were not permitted to have ABHR. The surveyor also observed wet nesting on dome plate covers, GNAs shaking moisture from the covers before placing them on plates, and dietary staff touching a keypad and then double doors before being directed to wash their hands. Additional observations showed rusted and damaged over-the-toilet commodes in resident rooms, a full portable urinal placed on top of a bedside dresser in front of resident food items, and residents in the dining room without performing hand hygiene. In the kitchen, a staff member wore a winter scarf around her neck while working, and the kitchen thermostat was set at 53 degrees Fahrenheit. In the laundry area, the surveyor observed damaged walls and flooring, a heavily stained handwashing sink and mop sink, soiled chemical storage racks, improper storage of mops and buckets between washers, and ventilation problems in both the soiled and clean laundry rooms. The surveyor also observed an oxygen tube attached to an oxygen cylinder in the oxygen storage room, and IV poles stored uncovered with dirt or spills present, with staff stating cleaned poles were returned to the locked supply room without confirmation that EVS had cleaned and disinfected them. The Infection Preventionist confirmed that the infection control issues had been shared by staff throughout the survey period.
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.
Resident Funds Access
Penalty
Summary
The facility failed to assure that residents whose funds were managed by the facility had ready and reasonable access to their money. During interview, the Business Office Manager stated that residents had to come to the front and request cash from the receptionist or Business Office staff, and that if the money was not in the cash box it would be obtained by the next day. The Business Office Manager also stated that residents received money only after signing for it, and that after hours and on weekends residents could get only $5 or $10. The surveyor later informed the Business Office Manager that residents were supposed to have access to their account at any time and could access up to $100 immediately, or $50 for Medicaid residents, with amounts over $100 available within three days. The deficient practice had the potential to affect 58 of the 93 residents whose accounts were being managed by the facility.
Failure to Provide Written Bed Hold Notice
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to the resident and/or the resident representative when the resident was transferred from the facility to an acute care facility for a change in medical condition. Review of the medical record for Resident #2 showed the transfer occurred on 8/24/2025, but the record did not contain written evidence that the bed hold policy had been given to or received by the resident or the resident representative. During an interview, the Administrator stated that she mailed the bed hold policy to the resident's representative, but she was unable to produce written evidence that the notice was provided or received, and acknowledged that the lack of written proof of notification was an issue.
Failure to Develop Person-Centered Care Plans for Wandering Risk, Oral Hygiene Needs, and ADL Refusal
Penalty
Summary
Facility staff failed to initiate person-centered care plans for a resident who was high risk for wandering/elopement, a resident who required assistance with oral hygiene, and a resident who frequently refused ADL care. During observation rounds, Resident #40 was noted to have several missing teeth, with the remaining teeth discolored and decayed. A dental assessment from Health Drive stated the resident could not perform oral hygiene independently. During interviews, the RN Unit Manager stated the facility did not ask about recent vision, dental, or audiology care on admission and that residents were usually enrolled into Health Drive, but they did not care plan for all services. The DON stated the ADL care plan for Resident #40 indicated the GNA set the resident up for teeth brushing, but the surveyor noted that setting the resident up was not the same as brushing the resident's teeth, and the care plan did not indicate staff brushed the resident's teeth. The resident also had an elopement assessment showing high risk for wandering/elopement, but a person-centered care plan was not initiated when that risk was identified. For Resident #11, PCC task documentation showed showers were scheduled twice weekly, but showers were not documented on two scheduled dates, and there was no progress note explaining why the showers were missed. During interview, the DON stated the resident refused showers, but prior to the end of the survey the requested care plan for refusal of ADL care was not provided. The record review and interviews showed the facility did not have person-centered care plans in place for the identified needs and refusals.
Failure to Document Missed Enteral Nutrition
Penalty
Summary
The facility failed to adhere to professional nursing standards when staff did not document why a resident did not receive enteral nutrition. Resident #10 had an enteral feeding order dated 11/30/25 for Jevity 1.5 at 55 ml/hour for 20 hours a day, with a total volume of 1100 ml in 24 hours. Review of the record showed the volume of tube feeding received was documented as zero on 12/2, 12/3, and 12/4, and on 12/10 the record contained an x and a 9 indicating a note should be present, but no note was found in PCC explaining why the feeding was not given. During observation on 12/11/25 at 9:11 am, the resident's tube feeding was not infusing for at least 10 minutes. An LPN entered the room, stated the pump was beeping, attempted to restart it, and found a lot of air in the tubing. The LPN said another bag would be obtained to restart the feeding, and at least 30 to 45 minutes passed without the resident receiving enteral nutrition. During interview, the RN Unit Manager stated that if the resident did not receive nutrition, the physician should have been notified and a note should have been written.
Missing Annual Performance Review for GNA
Penalty
Summary
The facility failed to conduct yearly performance reviews at least every 12 months for 1 of 2 Geriatric Nursing Assistant (GNA) personnel files reviewed during the recertification survey. Review of Staff #8’s GNA record on 12/18/2025 at 10:13 AM showed that the last 12-month performance review had been completed on 5/17/2024. During an interview on 12/18/2025 at 10:30 AM, the Director of Nursing stated that there was no 2025 performance evaluation available for Staff #8. The DON acknowledged that GNA performance evaluations should be completed annually.
Failure to Address Pharmacist Recommendation for Midodrine Timing
Penalty
Summary
The facility failed to respond in a timely manner to a consulting pharmacist’s recommendation documented in the Medical Management Review for Resident #4. During review of the resident’s medical record and MAR, surveyors found that the pharmacist had made two recommendations, and only one had been addressed by the PA with a written order, signature, and date on the MMR. The second recommendation remained unaddressed, and the PA later acknowledged that the recommendation should have been addressed. The unaddressed recommendation involved Midodrine 5 mg ordered three times daily for hypotension. The consulting pharmacist noted that Midodrine should be given no later than 6:00 PM, or 3 to 4 hours before bedtime, to avoid supine hypertension, but the MAR showed the resident was still receiving the medication at 9:00 AM, 1:00 PM, and 9:00 PM. The pharmacist’s recommendation was dated 11/7/2025, and the record review on 12/15/2025 showed the evening dose had not been changed. During interview, Staff #32 confirmed the signature on the MMR and stated that the order had been missed.
Meals Served Unpalatable, Inadequately Portioned, and at Improper Temperatures
Penalty
Summary
The facility failed to ensure that resident meals were palatable, sufficiently portioned, and maintained outside of the food danger zone. This was identified during the annual survey based on observations, record review, and interviews involving 2 residents. On 12/11/2025, Resident #82’s POA stated by telephone that the resident was not receiving adequate food portions, and Resident #5 reported that the food lacked acceptable taste and texture. Resident #5 specifically stated that the roast beef served for dinner on 12/10/2025 was tough, resembled rubber, and could not be cut with a butter knife. During observation on 12/16/2025, Staff #21 asked Staff #23 to retrieve another batch of scrambled eggs with cheese from the kitchen while scraping the bottom of the food pan in front of the Choptank unit. Staff #23 stated that an additional sheet pan of scrambled eggs had been placed in the steam table, but Staff #21 noted that the eggs in the steam table did not have cheese, and residents who had ordered scrambled eggs with cheese had been served without cheese. On 12/17/2025, the surveyor and the HCSG Regional Manager took internal temperatures of the last test plate at the Choptank unit and recorded temperatures of 97 degrees F for sliced roast pork sandwich, 121 degrees F for sliced roast pork in the steam table pan, 117 degrees F for mashed potatoes, 112 degrees F for mixed vegetables, and 57 degrees F for applesauce stored on the pushcart from the previous night.
Failure to Identify Governing Body and Responsible Leadership
Penalty
Summary
The facility was cited for failing to establish a governing body that is legally responsible for establishing and implementing policies for the management and operation of the facility and for appointing a properly licensed administrator responsible for managing the facility. During the QAPI process and interview, staff were unable to report who was legally responsible for establishing and implementing policies related to the facility’s management and operations. During an interview with the Administrator, the surveyor asked questions about the governing body, and the Administrator stated she did not know what the surveyor was referring to. The Administrator said the facility had corporate leadership that came to the building, but she was uncertain who was legally responsible for the building and its leadership.
Essential Kitchen Equipment Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to maintain essential kitchen equipment in proper operating condition, as shown by observations of 4 of 4 pieces of equipment reviewed during the annual survey. On 12/10/2025 at 7:40 AM, the surveyor observed an inoperable steam table located in front of the cookline, and the HCSG District Manager confirmed that the steam table was nonfunctional. Later that morning, at 7:55 AM, the surveyor observed that the Type 2 ventilation system above the high-temperature mechanical dishwasher was not adequately removing steam, with steam escaping from the sides of the dishwasher and dissipating throughout the kitchen area. At 8:20 AM, the surveyor observed the walk-in freezer with excessive ice, frost, an ice dam, and icicles on the walls, floor, ceiling, and food shelving units, with food boxes, ice cream/frosting tubs, food pans, and bags of ice also covered because of the malfunction. At 9:20 AM, the surveyor reevaluated the dishwasher ventilation by using a smoke stick and observed that the smoke was drawn only halfway toward the ventilation opening before gradually pulling vertically into the kitchen rather than horizontally into the unit. The Administrator, Regional Maintenance Director, Maintenance Director, and HCSG District Manager witnessed these observations, and later the steam table was again observed turned off and inoperable, with the HCSG District Manager confirming it remained nonfunctional.
Inaccessible Call Bell System
Penalty
Summary
The facility failed to ensure that a call bell system was accessible to residents in a bathroom and bathing area. During the annual survey, Resident #8 was seated in a wheelchair at the foot of the bed and, when asked to press the call bell for assistance due to reported pain and discomfort, was unable to reach it because the call bell was positioned behind the wheelchair. The resident stated this was the designated location for the call bell each morning when seated in the wheelchair. The surveyor later reported the resident’s discomfort to the nurses’ station and requested repositioning, and also documented the time elapsed while waiting at the resident’s door because the call bell was inaccessible. In a separate observation, a restroom call bell cord in room [ROOM NUMBER] was noted to be too short to be reached by a resident on the floor.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 134 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 44 | 0 |
| Pines Nursing And Rehab | 12.9 mi | ★★★★★ | 90 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.