Public Record
Autumn Lake Healthcare at Spa Creek
From CMS
Facility profile
- CMS overall rating
- 3 / 5
- Certified beds
- 130
- Avg. residents per day
- 113.8
*CMS Five-Star
*CMS
*CMS
Inspection record
On record from CMS
- Citations on record
- 112
- Inspections on file
- 8
- Last inspection
- 2025-08-06
*CMS
*CMS
*CMS
Citations
112 citations on record
Each deficiency cited on a CMS health inspection of this facility, sourced from the federal record. Open a report for the raw CMS Scope and Severity grade on each finding.
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0761Generalpotential for harm
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.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0908Generalpotential for harm
Keep all essential equipment working safely.
- 0628Generalpotential for harm
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0658Generalpotential for harm
Ensure services provided by the nursing facility meet professional standards of quality.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0680Generalno actual harm
Ensure the activities program is directed by a qualified professional.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0914Generalpotential for harm
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0223Generalpotential for harm
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- 0293Generalpotential for harm
Have properly located and lighted "Exit" signs.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0567Generalpotential for harm
Honor the resident's right to manage his or her financial affairs.
- 0584Generalpotential for harm
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.
- 0925Generalpotential for harm
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- 0880Generalpotential for harm
Provide and implement an infection prevention and control program.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0840Generalpotential for harm
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0686Generalpotential for harm
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0584Generalpotential for harm
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.
- 0609Generalpotential for harm
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- 0835Generalpotential for harm
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
- 0100Generalpotential for harm
Meet other general requirements.
- 0211Generalpotential for harm
Keep aisles, corridors, and exits free of obstruction in case of emergency.
- 0222Generalpotential for harm
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- 0232Generalpotential for harm
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
- 0281Generalpotential for harm
Install proper backup exit lighting.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0324Generalpotential for harm
Provide properly protected cooking facilities.
- 0345Generalpotential for harm
Have approved installation, maintenance and testing program for fire alarm systems.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0362Generalpotential for harm
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- 0511Generalpotential for harm
Have properly installed electrical wiring and gas equipment.
- 0741Generalpotential for harm
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
- 0761Generalpotential for harm
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.
- 0781Generalpotential for harm
Have restrictions on the use of portable space heaters.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0923Generalpotential for harm
Have proper medical gas storage and administration areas.
- 0550Generalpotential for harm
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
- 0558Generalpotential for harm
Reasonably accommodate the needs and preferences of each resident.
- 0559Generalpotential for harm
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
- 0584Generalpotential for harm
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.
- 0600Generalpotential for harm
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- 0603Generalpotential for harm
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
- 0610Generalpotential for harm
Respond appropriately to all alleged violations.
- 0636Generalpotential for harm
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- 0638Generalpotential for harm
Assure that each resident’s assessment is updated at least once every 3 months.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0677Generalpotential for harm
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 0679Generalpotential for harm
Provide activities to meet all resident's needs.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0732Generalpotential for harm
Post nurse staffing information every day.
- 0740Generalpotential for harm
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0921Generalpotential for harm
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- 0759Generalpotential for harm
Ensure medication error rates are not 5 percent or greater.
- 0760Seriousimmediate jeopardy
Ensure that residents are free from significant medication errors.
- 0809Generalpotential for harm
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
- 0812Generalpotential for harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- 0842Generalpotential for harm
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- 0883Generalpotential for harm
Develop and implement policies and procedures for flu and pneumonia vaccinations.
- 0565Generalpotential for harm
Honor the resident's right to organize and participate in resident/family groups in the facility.
- 0604Generalpotential for harm
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
- 0623Generalpotential for harm
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- 0625Generalpotential for harm
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
- 0641Generalpotential for harm
Ensure each resident receives an accurate assessment.
- 0655Generalpotential for harm
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- 0656Generalpotential for harm
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- 0657Generalpotential for harm
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- 0684Generalpotential for harm
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- 0689Generalpotential for harm
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- 0692Generalpotential for harm
Provide enough food/fluids to maintain a resident's health.
- 0730Generalpotential for harm
Observe each nurse aide's job performance and give regular training.
- 0755Generalpotential for harm
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- 0756Generalpotential for harm
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- 0757Generalpotential for harm
Ensure each resident’s drug regimen must be free from unnecessary drugs.
- 0918Generalpotential for harm
Have generator or other power source capable of supplying service within 10 seconds.
- 0431Generalpotential for harm
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
- 0371Generalpotential for harm
Store, cook, and serve food in a safe and clean way.
- 0315Generalpotential for harm
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
- 0274Generalpotential for harm
Review or revise the resident's care plan after any major change in physical or mental health.
- 0166Generalpotential for harm
Try to resolve each resident's complaints quickly.
- 0271Generalpotential for harm
Have exits that are accessible at all times.
- 0321Generalpotential for harm
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- 0353Generalpotential for harm
Inspect, test, and maintain automatic sprinkler systems.
- 0363Generalpotential for harm
Install corridor and hallway doors that block smoke.
- 0372Generalpotential for harm
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- 0712Generalpotential for harm
Have simulated fire drills held at unexpected times.
- 0911Generalpotential for harm
Meet requirements for the installation and maintenance of electrical systems.
- 0514Generalpotential for harm
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Inspection history
Every health inspection on record
Each CMS health inspection of this facility, and the deficiencies the surveyors cited. Where the verbatim Form 2567 statement of deficiencies is on file, it links to the full report.
- View inspection reportInspection29 deficiencies
- View inspection reportInspection29 deficiencies
- View inspection reportInspection11 deficiencies
- View inspection reportInspection37 deficiencies
- View inspection reportInspection37 deficiencies
- View inspection reportInspection21 deficiencies
- View inspection reportInspection14 deficiencies
- View inspection reportInspection14 deficiencies
FAQ
Questions and answers
- What is Autumn Lake Healthcare at Spa Creek?
- Autumn Lake Healthcare at Spa Creek is a Medicare- and Medicaid-certified nursing home in Annapolis, MD, tracked by the Centers for Medicare & Medicaid Services (CMS). Its CMS Certification Number (CCN) is 215258.
- What is the CMS rating for Autumn Lake Healthcare at Spa Creek?
- Autumn Lake Healthcare at Spa Creek has a CMS overall rating of 3 out of 5 stars. CMS rates nursing homes on health inspections, staffing, and quality measures.
- How many beds does Autumn Lake Healthcare at Spa Creek have?
- Autumn Lake Healthcare at Spa Creek is certified for 130 beds. It serves an average of 113.8 residents per day.
- How many citations does Autumn Lake Healthcare at Spa Creek have?
- Autumn Lake Healthcare at Spa Creek has 112 citations on record from CMS health inspections, each tied to a federal deficiency tag.
- When was Autumn Lake Healthcare at Spa Creek last inspected?
- Autumn Lake Healthcare at Spa Creek was last inspected on August 6, 2025. CMS surveys nursing homes about once a year and after complaints.
- What can I do if I have concerns about care at this facility?
- Start by raising the concern with the facility administrator or director of nursing. Every state also runs a free long-term care ombudsman program that advocates for residents and families; the federal Eldercare Locator at eldercare.acl.gov can connect you with yours. Complaints about quality of care can also be filed with your state survey agency.
*Sourced from the Centers for Medicare & Medicaid Services (CMS). See the official record on CMS Care Compare. If you believe any information is inaccurate, report it here.
/nursing-home/215258-autumn-lake-healthcare-at-spa-creek