Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Spa Creek during CMS and state inspections, most recent first.
A deficiency was identified when the door alarm system for a stairwell exit failed to sound an audible alert at the nursing station after the door was opened without entering a code. Although a panel light illuminated, four staff members present did not recognize this as an alert, and the Maintenance Director confirmed the alarm should have sounded. The issue was traced to a wiring problem, resulting in the alarm not functioning as intended.
Surveyors identified multiple failures by nursing staff to follow professional standards, including not administering medications as documented, improper medication administration via PEG tube, and lack of communication or documentation when a resident requested a different dose of anxiety medication. These deficiencies involved several residents and resulted in inaccurate records and unmet care needs.
Surveyors found that the facility failed to maintain a safe, clean, and comfortable environment, with multiple rooms having damaged furniture, missing or loose molding, exposed drywall, and unsanitary conditions. A resident reported prolonged disrepair of a wheelchair and dirty privacy curtains, with surveyors confirming these issues during their inspection.
Facility staff did not accurately code MDS assessments for four residents, failing to document opioid use, scheduled pain medications, anticonvulsant administration, antibiotic use, topical treatments, and a fall event. These omissions were confirmed by the MDS Coordinator as oversights during the survey.
Staff failed to follow infection control protocols, including not performing hand hygiene between resident contacts and after handling soiled items. Multiple resident bathrooms contained uncovered, unlabeled, and improperly stored basins and urinals, with some containing soiled materials or stacked together without protection. The Infection Control Nurse confirmed these practices did not align with facility policy.
The facility did not maintain an effective pest control program, as evidenced by repeated reports and observations of roach and ant activity in resident rooms, pantries, kitchen, and nurses stations. Pest control logs and vendor reports documented ongoing infestations and contributing factors such as poor sanitation and standing water, while direct observations and interviews confirmed persistent pest presence throughout the facility.
A GNA was observed standing while feeding two residents and speaking in a harsh, loud tone to another resident to wake them for breakfast. These actions, including quickly shoveling food and failing to sanitize hands between resident contacts, did not honor residents' rights to dignity and respectful communication.
A resident was found at a nursing station with a bed sheet tied in a knot around their back, and the incident was reported by housekeeping staff to a GNA after initially being unable to find staff on the first floor. Although the charge nurse was promptly informed, the required report to OHCQ was not submitted within the mandated 2-hour period, as confirmed by the DON.
Facility staff did not complete neuro checks at the required intervals or with current vital signs for two residents following unwitnessed falls, despite provider instructions and facility protocol. Nursing leadership confirmed that neuro checks were missed or performed inaccurately.
Facility staff failed to administer prescribed pressure ulcer treatments for two residents, including missing several days of ordered wound care and delaying the initiation of treatment for a deep tissue injury. Staff also did not complete required weekly wound assessments and measurements on multiple occasions, as confirmed by nursing leadership.
A resident admitted with multiple fractures and pain management needs did not receive prescribed controlled medications in a timely manner due to delays in order processing and pharmacy authorization. Despite requests from the resident and family, the medications were not administered, leading the spouse to sign the resident out against medical advice to seek care elsewhere. Nursing documentation showed alternative pain medications were offered and refused, but pain levels were not recorded. Facility investigation confirmed the medications were not made available as required.
Facility staff did not timely arrange required outside specialist appointments for two residents, including neurology, urology, pulmonology, and orthopedics, as directed by hospital discharge instructions. One resident did not have a neurology follow-up scheduled, and another experienced significant delays and lack of evidence of visits to pulmonology and orthopedics, as confirmed by facility leadership.
A resident with a history of bladder neck obstruction had a physician order for a cystoscopy, but the results of this procedure were not present in the medical record. This was confirmed by the Administrator during a survey, indicating incomplete and inaccurate documentation.
Failure to Maintain Operational Door Alarm System
Penalty
Summary
During a recertification survey, a deficiency was identified regarding the facility's failure to ensure that essential equipment, specifically the door alarm operating system, was functioning as intended. The surveyor and the Maintenance Director (MD) tested the exit door alarm system in the first-floor stairwell following concerns related to a recent elopement. The MD explained the system's operation, stating that an audible alarm should sound at the first-floor nursing station if the door is opened without entering a code. However, when the door was opened without the code, the alarm did not sound, although the number 36 illuminated on the panel. Four staff members present at the nursing station were unaware that the illuminated number indicated the door had been opened, as there was no audible alert. The MD confirmed that an audible alarm should have been triggered and subsequently discovered that connecting two wires in the wall panel caused the alarm to sound. This sequence of events demonstrated that the door alarm system was not operational as required, and staff were not alerted to the door being opened, constituting a failure to maintain essential safety equipment.
Failure to Meet Professional Standards in Medication Administration and Documentation
Penalty
Summary
The facility failed to ensure that nursing staff provided services in accordance with professional standards of practice, as evidenced by multiple medication administration errors and documentation discrepancies observed during a recertification survey. In several instances, LPNs documented the administration of medications that were not actually given to residents. For example, one LPN recorded that a topical medication was applied to a resident's foot, but this was not observed during the medication pass. Similarly, another LPN signed off on the administration of an oral antiviral medication that was not given, and a blood thinner that was not administered to another resident. There were also issues with the administration of medications via PEG tube, where an LPN crushed and attempted to administer an enteric-coated medication that was labeled 'do not crush,' and failed to ensure that all medications were fully dissolved and delivered. The LPN did not follow physician orders regarding the required water flushes before and after medication administration, and signed off on the administration of a medication that was not observed to be given. Additionally, there were two active and potentially conflicting orders for a lidocaine patch for one resident, leading to the application of a patch for an extended period without proper clarification until after the surveyor's intervention. Another deficiency involved a resident who reported anxiety and requested a specific dose of lorazepam that had previously been effective. The LPN did not administer the medication, did not document the resident's refusal or request for a different dose, and did not notify the physician as required by facility policy. Review of the medication administration record and narcotic log confirmed that the medication was not given and was instead wasted, with no documentation of communication with the physician or follow-up regarding the resident's request.
Failure to Maintain Safe and Homelike Environment Due to Poor Maintenance
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance of a safe, clean, and comfortable environment for residents. On three of four hallways on the second-floor nursing unit, several resident rooms had furniture with missing or peeling laminate, exposed particle board, cracked vinyl on wheelchair armrests, missing or damaged drawer handles, and rusted toilet riser frames. Additional issues included loose or missing baseboard molding, holes in ceilings and molding, exposed drywall above heaters, dirty fans, broken bathroom sink drains, and plastic pipes left on the floor. These conditions were confirmed by the Maintenance Director during an environmental tour. A resident reported that their wheelchair had been in disrepair since September 2023, with unsecured arms and sharp metal corners, requiring the use of a seat pad for protection. The same resident also noted a dirty privacy curtain with a brown spot and a worn footboard with missing material and baseboard molding. These observations were confirmed by the surveyor during interviews and room inspections. The facility staff were aware of these issues, as acknowledged by the Nursing Home Administrator, but the necessary maintenance and repairs had not been completed at the time of the survey.
Inaccurate Coding of MDS Assessments for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for four residents during a complaint survey. In one case, a resident received Oxycodone for pain, but the MDS assessment did not capture the use of an opioid. Another resident was administered scheduled pain medications, including Lidocaine patches, Voltaren gel, and Gabapentin for osteoarthritis, but the MDS failed to document the use of scheduled pain medications and anticonvulsants. The MDS Coordinator confirmed these omissions during interviews, attributing them to oversight. Additionally, a resident who was administered Amoxicillin for a urinary tract infection and received Zinc Oxide cream for skin treatment was not accurately coded for antibiotic use or topical medication application on the MDS. Another resident with a history of falls experienced a fall during their stay, but both the quarterly and discharge MDS assessments failed to document this event. The MDS Coordinator acknowledged these errors, confirming that the assessments did not accurately reflect the residents' conditions and treatments.
Failure to Follow Infection Control Practices and Proper Storage of Resident Care Items
Penalty
Summary
Facility staff failed to adhere to infection control practices as observed during a complaint survey on one of two nursing units. Specifically, a Geriatric Nursing Assistant (GNA) was seen feeding one resident, then setting up another resident's breakfast tray, and returning to the first resident without sanitizing her hands between resident contacts. The same GNA was later observed feeding another resident, handling soiled breakfast trays, and entering another room without performing hand hygiene after contact with residents and contaminated items. Additionally, multiple resident bathrooms on the second-floor nursing unit were found to have uncovered, unlabeled, and improperly stored basins and urinals. Some basins contained used paper towels, soiled utensils, or were stacked inside each other without protective plastic. Dirty containers and soiled washcloths were also observed in several bathrooms. The Infection Control Nurse confirmed that basins should be cleaned, dried, labeled, and stored in plastic bags, but acknowledged that current practices did not meet these standards and that the only available policy addressed cleaning and returning bath basins to storage.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented instances of pest activity, including roaches and ants, in various areas such as the kitchen, nurses stations, pantries, and 26 out of 70 resident rooms. Review of the facility's and vendor's pest control logs from January through May revealed repeated reports and observations of roach and ant activity in resident rooms, common areas, and service areas. Specific entries noted heavy and moderate pest activity, with some areas showing persistent problems over several months. Vendor pest control logs corroborated these findings, documenting frequent inspections and treatments for roach and ant activity in resident rooms, pantries, kitchen, dish room, and nurses stations. The vendor also observed poor sanitation and standing water in the dish room, which were identified as contributing factors to ongoing pest issues. Despite regular treatments, pest activity was repeatedly observed on monitors and during service visits, indicating that the measures in place were not sufficient to control the infestation. Direct observations by surveyors and staff interviews further confirmed the presence of pests, including live sightings of ants and roaches in resident rooms, pantries, and vending areas. One resident reported seeing a bed bug and stated that staff had not followed up on the concern. These findings collectively demonstrate that the facility did not have an effective pest control program in place to prevent or address infestations, resulting in ongoing pest activity in both resident and common areas.
Failure to Maintain Resident Dignity During Feeding and Communication
Penalty
Summary
Facility staff failed to treat residents in a dignified manner during mealtime assistance. A Geriatric Nursing Assistant (GNA) from a staffing agency was observed standing while feeding a resident and quickly shoveling food into the resident's mouth. In the same room, another resident was found sleeping in bed with their breakfast tray left covered on the bedside table. The GNA then approached the sleeping resident and repeatedly spoke in a harsh and loud tone, instructing the resident to wake up for breakfast. These actions were directly observed by the surveyor. Additionally, the same GNA was later seen standing while feeding another resident in the dining room, with another resident present at the same table. The Director of Nursing (DON) was informed of these observations, including the GNA's failure to sanitize hands between resident contacts. The DON acknowledged that the GNA's behavior was inappropriate and not in accordance with facility expectations.
Failure to Timely Report Alleged Abuse to Regulatory Agency
Penalty
Summary
The facility failed to report an allegation of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe. On the morning of 9/27/23, a housekeeping staff member observed a resident at the first-floor nursing station in a wheelchair with a bed sheet tied in a knot around their back. Unable to find anyone to report the incident to on the first floor, the housekeeper went to the second-floor nursing unit and informed a GNA. The charge nurse on the second floor overheard this and immediately notified the first-floor charge nurse. Despite these actions, facility documentation shows that the initial report to OHCQ was not made until later that afternoon, well beyond the mandated 2-hour window. The DON confirmed during an interview that the report was not submitted within the required timeframe.
Failure to Perform Timely and Accurate Neuro Checks After Falls
Penalty
Summary
Facility staff failed to properly perform neurological checks after falls for two residents, as required by facility protocol. One resident, admitted with a history of falls, experienced an unwitnessed fall in the bathroom. Although the provider was notified and recommended monitoring per protocol, staff did not complete neuro checks at the required intervals and, in some instances, used outdated vital signs. Several scheduled neuro checks were missed, and the night shift did not complete the required assessments. Another resident, admitted with weakness, had an unwitnessed fall and was found sitting between the bed and wall. The provider instructed staff to follow the facility's neuro check protocol, but staff again failed to perform neuro checks at the correct intervals, omitted some checks, and used vital signs from several hours prior. Interviews with nursing leadership confirmed that neuro checks were not completed accurately or according to the established schedule for both residents.
Failure to Provide Timely Pressure Ulcer Care and Assessment
Penalty
Summary
Facility staff failed to provide appropriate treatment and services to prevent and heal pressure ulcers for two residents. One resident, admitted with a history of cerebral infarction, was documented by the Wound Nurse Practitioner (WNP) to have an unstageable sacral pressure ulcer. The prescribed treatment regimen included cleansing with dakins and applying santyl with dakins wet to dry dressing daily. However, medical record review showed that staff did not administer the ordered treatment on three consecutive days, as confirmed by the Director of Nursing. Another resident, who was readmitted from the hospital, was assessed by the WNP to have a Stage 3 sacral pressure ulcer. Facility staff failed to complete weekly wound assessments, including measurements, on three separate occasions. Additionally, although a left heel wound was identified, treatment for a deep tissue injury (DTI) was not initiated until nearly two weeks after the wound was first documented. The Assistant Director of Nursing confirmed these lapses in wound assessment and delayed initiation of treatment.
Failure to Provide Timely Access to Prescribed Medications After Admission
Penalty
Summary
The facility failed to provide timely access to prescribed medications for a resident admitted from an acute care hospital with multiple fractures and pain management needs. Upon admission, the resident had orders for several controlled substances, including hydromorphone for pain, alprazolam and lorazepam for anxiety, and pregabalin for nerve pain. Despite these orders, the medications were not administered on the day of admission, as documented in the Medication Administration Record. The resident and family requested pain medication within two hours of arrival, but were informed that the orders needed to be cleared by the physician due to their controlled status. After six hours without receiving the prescribed medications, the resident's spouse signed the patient out against medical advice to seek medication at a hospital. Nursing notes indicated that the resident was assessed and offered alternative pain medications, which were refused, but did not document the resident's pain level. Interviews with staff revealed that the process for obtaining controlled substances required physician review and pharmacy authorization, even though some of the medications were available in the facility's Omnicell system. The facility's own investigation confirmed that the medications were not available as required and that orders should have been processed within four hours of admission. The deficiency was identified as an isolated incident involving a failure to ensure timely pharmaceutical services to meet the resident's needs.
Failure to Timely Obtain Outside Professional Services for Residents
Penalty
Summary
Facility staff failed to obtain necessary outside professional services for two residents as required. For one resident admitted with a diagnosis of cerebral infarction, the hospital discharge summary included instructions for a neurology follow-up. However, review of the medical record showed that no order was placed and no neurologist appointment was scheduled from admission through discharge. The DON confirmed that the neurology appointment was not scheduled. For another resident admitted with diagnoses including bladder neck obstruction, solitary pulmonary nodule, and low back pain, the hospital discharge summary required follow-up appointments with urology, pulmonology, and orthopedics. The urology appointment was not ordered until several months after admission, and although the resident was eventually seen by the urologist, the pulmonology and orthopedic appointments were not ordered until even later, with no evidence that the resident was seen by those specialists. The Administrator confirmed that these appointments were not ordered in a timely manner and that there was no evidence of visits to pulmonology or orthopedics.
Missing Diagnostic Test Results in Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident reviewed during a complaint survey. Specifically, a resident admitted with a diagnosis including bladder neck obstruction had a physician order for a cystoscopy. Upon review of both electronic and paper medical records, the results of the cystoscopy were not found. This omission was confirmed during an interview with the Administrator, who acknowledged that the medical record did not contain the required cystoscopy results. The deficiency was identified through medical record review and staff interview, demonstrating that the facility did not ensure all relevant diagnostic results were included in the resident's official medical record.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Annapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Annapolis | 0.7 mi | — | 11 | 0 |
| Baywoods Of Annapolis | 1.6 mi | — | 0 | 0 |
| Ginger Cove | 3 mi | — | 12 | 0 |
| South River Rehabilitation And Wellness Center | 3.5 mi | — | 19 | 0 |
| Future Care Annapolis | 4.6 mi | — | 0 | 0 |
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