Autumn Lake Healthcare At Chevy Chase

F 0609 Level of Harm - Minimal harm or potential for actual harm

Administrator stated allegations of abuse should be reported within two hours to the state survey agency.

According to the Administrator, the incident regarding Resident #1 and GNA #2 occurred during the 11:00 PM - 7:00 AM shift; she was notified by the DON of the incident and the incident was not reported to the state agency until 07/11/2025 at 2:00 PM.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/17/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Autumn Lake Healthcare at Chevy Chase

8700 Jones Mill Road Chevy Chase, MD 20815

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, record review, and facility policy review, the facility failed to perform hand hygiene between glove changes during wound care for 1 (Resident #4) of 3 sampled residents reviewed for pressure ulcers.Findings included: A facility policy titled, Clean Dressing Change, dated 12/13/2022, indicated, It is the policy of this facility to provide wound care in a manner to decrease potential for infection and/or cross-contamination. The policy indicated, 7. Wash hands and put on clean gloves. 8. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. 9. Loosen

the tape and remove the existing dressing. If needed to minimize skin stripping or pain, moisten with prescribed cleansing solution or use adhesive remover to remove tape. 10. Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. 11. Wash hands and put on clean gloves. 12.

Cleanse the wound as ordered, taking care not to contaminate other skin surfaces or other surfaces of the wound. Pat dry with gauze. 14. Wash hands and put on clean gloves. 15. Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. 16. Secure dressing. [NAME] with initials and date. 17. Discard disposable items and gloves into appropriate trash receptacle and wash hands. An admission Record indicated the facility admitted Resident #4 on 05/31/2015. According to the admission Record, the resident had a medical history that included a diagnosis of peripheral vascular disease. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 09/08/2025, revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. The MDS indicated the resident had one unstageable pressure ulcer. Resident #4's Care Plan Report included a focus area initiated 07/15/2025, that indicated the resident had an opened area to the sacrum noted on readmission.

Interventions directed staff to administer treatment as per physician order. During an observation on 10/15/2025 at 11:39 AM, Registered Nurse (RN) #14 and Geriatric Nursing Assistant #15 performed wound care for Resident #4. RN #14 removed the old dressing from the resident's sacrum, which exposed a very large deep unstageable wound that was covered with yellow slough. RN #14 removed his gloves and put on

a new pair of gloves without performing hand hygiene and then wiped the wound and the peri-wound with sterile water-soaked gauze then RN #14 applied body soap and a foaming cleansing soap on a 4 x 4 gauze, made the gauze sudsy, and covered the wound bed with the soap. RN #14 wiped the soap off with a gauze soaked in sterile water, not rinsing off the soap completely, and left visible soap on the wound. RN #14 patted the wound dry with gauze, removed his gloves, and put on a new pair of gloves without performing hand hygiene. RN #14 then soaked gauze with Dakin's solution then squeezed out all the liquid from the gauze and placed the gauze on the wound bed. He removed his gloves and put on a new pair of gloves without performing hand hygiene and placed dry sterile 4 x 4 gauze on top of the wet gauze. RN #14 removed his gloves and put on a new pair of gloves without performing hand hygiene then covered the wound with four individually wrapped 4 x 4 bordered gauze. He removed his gloves and retrieved a pen out of his pocket to date the dressing. RN #14 then went to the bathroom to wash his hands. During an

interview on 10/15/2025 at 12:02 PM, RN #14 stated hand hygiene should occur between glove changes.

He confirmed that he did not perform hand hygiene every time he changed his gloves but should have.

During an interview on 10/16/2025 at 4:26 PM, the Director of Nursing stated hand hygiene should occur

before the procedure and during the wound care, and anytime the staff removed their gloves they should perform hand hygiene in between the glove changes.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet