C+
69/100AUTUMN LAKE HEALTHCARE AT CHESAPEAKE WOODS Inspection Report, Violations & Safety Grade (CAMBRIDGE, Maryland)
525 GLENBURN AVENUE, CAMBRIDGE, Maryland 21613
Phone: 4102211400
CMS Overall:3/5
Overview & Bed Count
Certified Beds
98
Avg Residents/Day
94.4
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Dorchester
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall3/5
Health3/5
Staffing4/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Maryland Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.66 | 0.88 | -0.22 |
| Total Nurse Hours per Resident per Day | 4.02 | 3.93 | +0.09 |
| CMS Staffing Rating | 4/5 | 3.2/5 | - |
| Nursing Staff Turnover | 36.1% | 40.2% | - |
Health Citation History
49 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-19 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2025-12-19 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-12-19 | Environmental Deficiencies | Have enough outside ventilation via a window or mechanical ventilation, or both. | F – Moderate Harm Potential |
| 2025-12-19 | Resident Rights Deficiencies | Reasonably accommodate the needs and preferences of each resident. | E – Moderate Harm Potential |
| 2025-12-19 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2025-12-19 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-12-19 | Resident Rights Deficiencies | Honor the resident's right to manage his or her financial affairs. | D – Moderate Harm Potential |
| 2025-12-19 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-12-19 | Resident Rights Deficiencies | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D – Moderate Harm Potential |
| 2025-12-19 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2025-12-19 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2025-12-19 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | D – Moderate Harm Potential |
| 2025-12-19 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2025-12-19 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | D – Moderate Harm Potential |
| 2025-12-19 | Administration Deficiencies | Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | D – Moderate Harm Potential |
| 2025-12-19 | Environmental Deficiencies | Keep all essential equipment working safely. | D – Moderate Harm Potential |
| 2025-12-19 | Environmental Deficiencies | Make sure that a working call system is available in each resident's bathroom and bathing area. | D – Moderate Harm Potential |
| 2024-03-05 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-03-05 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2024-03-05 | Resident Assessment and Care Planning Deficiencies | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | D – Moderate Harm Potential |
| 2024-03-05 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2024-03-05 | Quality of Life and Care Deficiencies | Provide safe and appropriate respiratory care for a resident when needed. | D – Moderate Harm Potential |
| 2024-03-05 | Pharmacy Service Deficiencies | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | D – Moderate Harm Potential |
| 2024-03-05 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2024-03-05 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-03-05 | Pharmacy Service Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-03-05 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2024-03-05 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | D – Moderate Harm Potential |
| 2024-03-05 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2024-03-05 | Resident Rights Deficiencies | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | D – Moderate Harm Potential |
| 2024-03-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-03-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-03-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-03-05 | Nursing and Physician Services Deficiencies | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | D – Moderate Harm Potential |
| 2019-03-29 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | F – Moderate Harm Potential |
| 2019-03-29 | Nutrition and Dietary Deficiencies | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | E – Moderate Harm Potential |
| 2019-03-29 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2019-03-29 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2019-03-29 | Resident Rights Deficiencies | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | D – Moderate Harm Potential |
| 2019-03-29 | Resident Assessment and Care Planning Deficiencies | Ensure each resident receives an accurate assessment. | D – Moderate Harm Potential |
| 2019-03-29 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2019-03-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2019-03-29 | Nursing and Physician Services Deficiencies | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | D – Moderate Harm Potential |
| 2019-03-29 | Nursing and Physician Services Deficiencies | Observe each nurse aide's job performance and give regular training. | D – Moderate Harm Potential |
| 2019-03-29 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2019-03-29 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2019-03-29 | Nutrition and Dietary Deficiencies | Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | D – Moderate Harm Potential |
| 2019-03-29 | Resident Assessment and Care Planning Deficiencies | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | D – Moderate Harm Potential |
| 2019-03-29 | Environmental Deficiencies | Keep all essential equipment working safely. | D – Moderate Harm Potential |
Fire Safety Citation History
33 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-12-19 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2025-12-19 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2025-12-19 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2025-12-19 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | E – Moderate Harm Potential |
| 2025-12-19 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | E – Moderate Harm Potential |
| 2025-12-19 | Egress Deficiencies | Install proper backup exit lighting. | D – Moderate Harm Potential |
| 2025-12-19 | Egress Deficiencies | Have properly located and lighted "Exit" signs. | D – Moderate Harm Potential |
| 2025-12-19 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2025-12-19 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | D – Moderate Harm Potential |
| 2024-03-05 | Emergency Preparedness Deficiencies | Develop and maintain an Emergency Preparedness Program (EP). | F – Moderate Harm Potential |
| 2024-03-05 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | F – Moderate Harm Potential |
| 2024-03-05 | Services Deficiencies | Meet other general requirements that are deficient. | F – Moderate Harm Potential |
| 2024-03-05 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2024-03-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-03-05 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | E – Moderate Harm Potential |
| 2024-03-05 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | E – Moderate Harm Potential |
| 2024-03-05 | Egress Deficiencies | Install proper backup exit lighting. | E – Moderate Harm Potential |
| 2024-03-05 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-03-05 | Miscellaneous Deficiencies | Have restrictions on the use of portable space heaters. | E – Moderate Harm Potential |
| 2024-03-05 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2024-03-05 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | D – Moderate Harm Potential |
| 2024-03-05 | Smoke Deficiencies | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | D – Moderate Harm Potential |
| 2024-03-05 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | D – Moderate Harm Potential |
| 2024-03-05 | Services Deficiencies | Have properly installed electrical wiring and gas equipment. | D – Moderate Harm Potential |
| 2024-03-05 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | D – Moderate Harm Potential |
| 2024-03-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the installation and maintenance of electrical systems. | D – Moderate Harm Potential |
| 2024-03-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | D – Moderate Harm Potential |
| 2024-03-05 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2019-03-29 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | F – Moderate Harm Potential |
| 2019-03-29 | Miscellaneous Deficiencies | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | F – Moderate Harm Potential |
| 2019-03-29 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2019-03-29 | Smoke Deficiencies | Provide properly protected cooking facilities. | D – Moderate Harm Potential |
| 2019-03-29 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | D – Moderate Harm Potential |
Total Penalties & Fines
$50,879
Total Fine Amount (CMS)
2
Number of Fines
2
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-12-09 | Fine | $14,082 | - |
| 2024-05-02 | Fine | $36,797 | - |
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3-Year Complete Report ($19)
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Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the CAMBRIDGE area at no cost.
Find Safe, Vetted Facilities Near CAMBRIDGE
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.