Autumn Lake Healthcare at Spa Creek
35 Milkshake Lane · Annapolis, MD · 21403 · 4102695100
130 certified beds For profit - Limited Liability company Chain: Autumn Lake Healthcare
Why this verdict
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in prior inspection cycles
Serious past findings — check whether the underlying problems were fixed and stayed fixed.
Cited under the freedom-from-abuse rule
Cited 1 time under F600 (freedom from abuse/neglect) below the actual-harm level — worth asking about on a tour.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 3 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.59 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.53 | 0.55–0.75 |
| Weekend hours / resident-day | 3.26 | ≈ weekday level |
| Nursing turnover / year | 54% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (73 in the current record)
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Potential for harm · F August 6, 2025 · found via complaint
Keep all essential equipment working safely.
Corrected October 4, 2025 · Environmental
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Potential for harm · D August 6, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected October 4, 2025 · Resident Rights
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Potential for harm · D August 6, 2025
Honor the resident's right to manage his or her financial affairs.
Corrected October 4, 2025 · Resident Rights
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Potential for harm · D August 6, 2025
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.
Corrected October 4, 2025 · Resident Rights
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Potential for harm · D August 6, 2025
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected October 4, 2025 · Resident Rights
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Potential for harm · D August 6, 2025
Ensure each resident receives an accurate assessment.
Corrected October 4, 2025 · Resident Assessment and Care Planning
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Potential for harm · E August 6, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected October 4, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 6, 2025
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected October 4, 2025 · Resident Assessment and Care Planning
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Potential for harm · D August 6, 2025
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected October 4, 2025 · Quality of Life and Care
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Potential for harm · D August 6, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 4, 2025 · Quality of Life and Care
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Potential for harm · D August 6, 2025
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected October 4, 2025 · Pharmacy Service
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Potential for harm · D August 6, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected October 4, 2025 · Pharmacy Service
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Potential for harm · E August 6, 2025
Ensure medication error rates are not 5 percent or greater.
Corrected October 4, 2025 · Pharmacy Service
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Potential for harm · E August 6, 2025
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.
Corrected October 4, 2025 · Pharmacy Service
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Potential for harm · E August 6, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected October 4, 2025 · Nutrition and Dietary
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Potential for harm · D August 6, 2025
Provide and implement an infection prevention and control program.
Corrected October 4, 2025 · Infection Control
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Potential for harm · E August 6, 2025
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected October 4, 2025 · Infection Control
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Potential for harm · E August 6, 2025 · found via complaint
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected October 4, 2025 · Resident Assessment and Care Planning
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No harm found · C August 6, 2025
Ensure the activities program is directed by a qualified professional.
Corrected October 4, 2025 · Quality of Life and Care
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Potential for harm · D June 4, 2025 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 10, 2025 · Resident Rights
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Potential for harm · E June 4, 2025 · found via complaint
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.
Corrected July 10, 2025 · Resident Rights
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Potential for harm · D June 4, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected July 10, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E June 4, 2025 · found via complaint
Ensure each resident receives an accurate assessment.
Corrected July 10, 2025 · Resident Assessment and Care Planning
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Potential for harm · D June 4, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 10, 2025 · Quality of Life and Care
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Potential for harm · D June 4, 2025 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 10, 2025 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 215258 · certified since January 6, 1994. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.