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Health Inspection Summary

Autumn Lake Healthcare at Chevy Chase

8700 Jones Mill Road

Chevy Chase, MD 20815

(301) 657-8686

Deficiency Category	Inspection Date: 3/26/21 Complaint Reporting Period: 5/1/24 - 4/30/25	Inspection Date: 6/21/19 Complaint Reporting Period: 5/1/23 - 4/30/24	Inspection Date: 6/8/18 Complaint Reporting Period: 5/1/22 - 4/30/23
Freedom from Abuse, Neglect, and Exploitation Deficiencies	1	0	0
Quality of Life and Care Deficiencies	0	1	3
Infection Control Deficiencies	1	0	1
Resident Assessment and Care Planning Deficiencies	1	2	3
Nursing and Physician Services Deficiencies	0	0	0
Resident Rights Deficiencies	1	2	4
Nutrition and Dietary Deficiencies	0	1	1
Pharmacy Service Deficiencies	4	0	3
Environmental Deficiencies	0	0	0
Administration Deficiencies	0	1	1

Detailed result for inspection on 3/26/21

Date of last standard health inspection:	3/26/21Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/24 - 4/30/25	No complaint inspections
Date(s) of infection control inspection(s) between 5/1/24 - 4/30/25	No infection control inspections
Total number of Health Deficiencies for this nursing home:	8
Average number of Health Deficiencies in Maryland:	19.3
Average number of Health Deficiencies in the United States:	9.6

Freedom from Abuse, Neglect, and Exploitation Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.	3/26/21	5/6/21	2 - Minimal harm or potential for actual harm	Few

Quality of Life and Care Deficiencies
No Quality of Life and Care Deficiencies were found during this inspection period.

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide and implement an infection prevention and control program.	3/26/21	5/6/21	2 - Minimal harm or potential for actual harm	Few

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident receives an accurate assessment.	3/26/21	5/6/21	1 - Potential for minimal harm	Some

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	3/26/21	5/6/21	2 - Minimal harm or potential for actual harm	Few

Nutrition and Dietary Deficiencies
No Nutrition and Dietary Deficiencies were found during this inspection period.

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Ensure each resident’s drug regimen must be free from unnecessary drugs.	3/26/21	5/6/21	2 - Minimal harm or potential for actual harm	Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	3/26/21	5/6/21	2 - Minimal harm or potential for actual harm	Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.	3/26/21	5/6/21	2 - Minimal harm or potential for actual harm	Few
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	3/26/21	5/6/21	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
No Administration Deficiencies were found during this inspection period.

Detailed result for inspection on 6/21/19

Date of last standard health inspection:	6/21/19Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/23 - 4/30/24	No complaint inspections
Date(s) of infection control inspection(s) between 5/1/23 - 4/30/24	No infection control inspections
Total number of Health Deficiencies for this nursing home:	7
Average number of Health Deficiencies in Maryland:	14.5
Average number of Health Deficiencies in the United States:	9.5

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	6/21/19	8/1/19	2 - Minimal harm or potential for actual harm	Some

Infection Control Deficiencies
No Infection Control Deficiencies were found during this inspection period.

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	6/21/19	8/1/19	2 - Minimal harm or potential for actual harm	Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	6/21/19	8/1/19	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	6/21/19	8/1/19	2 - Minimal harm or potential for actual harm	Few
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.	6/21/19	8/1/19	1 - Potential for minimal harm	Some

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	6/21/19	8/1/19	2 - Minimal harm or potential for actual harm	Some

Pharmacy Service Deficiencies
No Pharmacy Service Deficiencies were found during this inspection period.

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.	6/21/19	8/1/19	2 - Minimal harm or potential for actual harm	Few

Detailed result for inspection on 6/8/18

Date of last standard health inspection:	6/8/18Read the full report (PDF)
Date(s) of complaint inspection(s) between 5/1/22 - 4/30/23	No complaint inspections
Date(s) of infection control inspection(s) between 5/1/22 - 4/30/23	No infection control inspections
Total number of Health Deficiencies for this nursing home:	16
Average number of Health Deficiencies in Maryland:	12.1
Average number of Health Deficiencies in the United States:	8.8

Freedom from Abuse, Neglect, and Exploitation Deficiencies
No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period.

Quality of Life and Care Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Provide activities to meet all resident's needs.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Few
Provide appropriate treatment and care according to orders, resident’s preferences and goals.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Few
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Few

Infection Control Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Implement a program that monitors antibiotic use.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Some

Resident Assessment and Care Planning Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Few
Ensure each resident receives an accurate assessment.	6/8/18	7/19/18	1 - Potential for minimal harm	Some
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Few

Nursing and Physician Services Deficiencies
No Nursing and Physician Services Deficiencies were found during this inspection period.

Resident Rights Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.	6/8/18	7/19/18	1 - Potential for minimal harm	Some
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.	6/8/18	7/19/18	1 - Potential for minimal harm	Some
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	6/8/18	7/19/18	1 - Potential for minimal harm	Some

Nutrition and Dietary Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Few

Pharmacy Service Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Some
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Some
Ensure each resident’s drug regimen must be free from unnecessary drugs.	6/8/18	7/19/18	2 - Minimal harm or potential for actual harm	Few

Environmental Deficiencies
No Environmental Deficiencies were found during this inspection period.

Administration Deficiencies
Inspectors determined that the nursing home failed to:	Inspection Date	Date of Correction	Level of Harm (Least to most)	Residents Affected (Few, Some, Many)
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	6/8/18	7/19/18	1 - Potential for minimal harm	Many

Complaints and facility-reported incidents in the past 3 years
This nursing home has not been cited for any deficiencies from incidents reported by the nursing home or complaints in the last 3 years.

Infection control inspection deficiencies in the past 3 years
This nursing home has not had any infection control inspections in the past 3 years.

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