Autumn Lake Healthcare At Waugh Chapel
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the nursing staff failed to follow a physician's orders for withholding an antihypertensive medication when the resident's blood pressure reading was less than 110 mm/Hg. This was evident for 1 of 2 residents (Resident #1) reviewed during the complaint survey.The findings include:Review of Complaint 2605041 on 11/19/25 at 12 noon revealed an allegation Resident #1 was not receiving quality of care at the facility.Resident #1 was admitted to the facility on [DATE REDACTED] with diagnoses that include but are not limited to post vascular surgery, arthritis, and hypertension. Resident #1 requires assistance from the nursing staff for some aspects of his/her care.Review of Resident #1's closed medical record on 11/19/25 at 12 noon revealed a physician order, dated 08/09/25, instructing the nursing staff to administer the blood pressure lowering medication, Amlodipine Besylate oral tablet, 2.5 mg, by mouth, one time a day, and hold for a systolic blood pressure reading less than 110 mm/Hg.A review of Resident #1's August and September 2025 Medication Administration Records (MAR) revealed the nursing staff were administering a dose of Amlodipine Besylate at 9 AM when Resident #1 blood pressure readings were less than 110 mm/Hg on the following days:08/11/2025 - 109/74.08/12/2025 - 109/74.08/14/2025 - 106/70.08/25/2025 - 106/70.08/28/2025 109/70.09/04/2025 - 100/60.In an interview with Staff Nurse #1 on 11/19/2025 at 3:40 PM, after reviewing Resident #1's August and September MAR's, Staff Nurse #1 stated that s/he should have withheld administering the dose of Amlodipine Besylate, 2.5 mg orally, to Resident #1 on 08/11/25, 08/14/25, 08/25/25, 08/28/25, and 09/04/25 due to Resident #1's blood pressure reading was less than 110 mm/Hg.
Residents Affected - Few
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
AUTUMN LAKE HEALTHCARE AT WAUGH CHAPEL in GAMBRILLS, MD inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in GAMBRILLS, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from AUTUMN LAKE HEALTHCARE AT WAUGH CHAPEL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.