Last Updated: October 2026
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Composite Quality Score

Comprehensive rating based on CMS data, staffing, quality measures, and compliance

B+
Grade
56
Score
CMS Ratings
12.5/22
Staffing Quality
9.2/20
Quality Measures
0.0/22
Compliance
18.0/18
Safety
13.0/13
Availability
6.0/10

Current Availability Estimate

Occupancy Rate89.2%
130
Total Beds
116
Occupied
14
Available

Basic Information

Address:

35 MILKSHAKE LANE

ANNAPOLIS, MD 21403

Number of Beds:

130

Estimated Occupancy:

89% (~14 available)

Chain:

AUTUMN LAKE HEALTHCARE

Quality Ratings

Overall Rating:3/5 Stars
Health Inspection:2/5 Stars
Staffing Rating:2/5 Stars
Quality Measures:5/5 Stars

Safety Information

Abuse Issues:No Issues Reported
Special Focus:Not Under Special Focus

Additional Information

CMS Certification Number:

215258

Provider Type:

Medicare and Medicaid

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Staffing Metrics

Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.

Registered Nurse (RN) Hours

Per resident per day

Below Average

This Facility

0.54

hours

National Avg

0.64

hours

Total Nursing Staff Hours

RN + LPN + Nurse Aides per resident per day

Below Average

This Facility

3.47

hours

National Avg

3.89

hours

Breakdown:

RN: 0.54hLPN: 1.22hAide: 1.71h

Staff Turnover Rate

Annual nursing staff turnover

Above Average

This Facility

52.5%

National Avg

46.6%

RN Turnover: 52.6%

Understanding Staffing Metrics

Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.

Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.

Detailed Quality Measures

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Health Inspections & Deficiencies

Critical Deficiencies Found

This facility has 2 deficiency citations involving actual harm to residents. Review these carefully before making a decision.

Total Deficiencies

104

Inspections

3

Critical

2

Feb 3, 2023 - Health Survey

50 deficiencies cited

Medium - PatternTag F0558

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Corrected: Apr 5, 2023
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Apr 5, 2023
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Apr 5, 2023
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Apr 5, 2023
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Apr 5, 2023
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Apr 5, 2023
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Apr 5, 2023
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Apr 5, 2023
Medium - PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Apr 5, 2023
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Apr 5, 2023
Medium - PatternTag F0921

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected: Apr 5, 2023
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0559

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Apr 5, 2023From Complaint
Medium - PatternTag F0603

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0636

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0638

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0732

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0558

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Corrected: Apr 5, 2023
Medium - PatternTag F0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected: Apr 5, 2023
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Apr 5, 2023
Medium - PatternTag F0677

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected: Apr 5, 2023
Medium - PatternTag F0679

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Corrected: Apr 5, 2023
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Apr 5, 2023
Medium - PatternTag F0761

Pharmacy Service Deficiencies

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: Apr 5, 2023
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Apr 5, 2023
Medium - PatternTag F0835

Administration Deficiencies

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected: Apr 5, 2023
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Apr 5, 2023
Medium - PatternTag F0921

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected: Apr 5, 2023
Medium - PatternTag F0550

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0559

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0584

Resident Rights Deficiencies

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: Apr 5, 2023From Complaint
Medium - PatternTag F0603

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0610

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0636

Resident Assessment and Care Planning Deficiencies

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0638

Resident Assessment and Care Planning Deficiencies

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0732

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0740

Quality of Life and Care Deficiencies

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0609

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Apr 5, 2023From Complaint
Medium - PatternTag F0658

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected: Apr 5, 2023From Complaint

Nov 5, 2018 - Health Survey

42 deficiencies cited

Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Dec 29, 2018
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Corrected: Dec 29, 2018
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Dec 29, 2018
Medium - PatternTag F0756

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected: Dec 29, 2018
Medium - PatternTag F0757

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected: Dec 29, 2018
Critical - Actual HarmTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Dec 29, 2018
Medium - PatternTag F0809

Nutrition and Dietary Deficiencies

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.

Corrected: Dec 29, 2018
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Dec 29, 2018
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Dec 29, 2018
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Dec 29, 2018
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Dec 29, 2018
Medium - PatternTag F0625

Resident Rights Deficiencies

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.

Corrected: Dec 29, 2018
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Dec 29, 2018
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Dec 29, 2018
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Dec 29, 2018
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Dec 29, 2018
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Dec 29, 2018
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Dec 29, 2018
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Dec 29, 2018
Medium - PatternTag F0730

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Corrected: Dec 29, 2018
Medium - PatternTag F0755

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected: Dec 29, 2018
Medium - PatternTag F0756

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected: Dec 29, 2018
Medium - PatternTag F0757

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected: Dec 29, 2018
Medium - PatternTag F0759

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Corrected: Dec 29, 2018
Critical - Actual HarmTag F0760

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Corrected: Dec 29, 2018
Medium - PatternTag F0809

Nutrition and Dietary Deficiencies

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.

Corrected: Dec 29, 2018
Medium - PatternTag F0812

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected: Dec 29, 2018
Medium - PatternTag F0842

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected: Dec 29, 2018
Medium - PatternTag F0883

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected: Dec 29, 2018
Medium - PatternTag F0565

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected: Dec 29, 2018
Medium - PatternTag F0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected: Dec 29, 2018
Medium - PatternTag F0565

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected: Dec 29, 2018
Medium - PatternTag F0604

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected: Dec 29, 2018
Medium - PatternTag F0623

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected: Dec 29, 2018
Medium - PatternTag F0625

Resident Rights Deficiencies

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.

Corrected: Dec 29, 2018
Medium - PatternTag F0641

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Corrected: Dec 29, 2018
Medium - PatternTag F0655

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected: Dec 29, 2018
Medium - PatternTag F0656

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected: Dec 29, 2018
Medium - PatternTag F0657

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected: Dec 29, 2018
Medium - PatternTag F0684

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected: Dec 29, 2018
Medium - PatternTag F0689

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected: Dec 29, 2018
Medium - PatternTag F0692

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Corrected: Dec 29, 2018

Jul 13, 2017 - Health Survey

12 deficiencies cited

Medium - PatternTag F0514

Administration Deficiencies

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Corrected: Aug 27, 2017
Medium - PatternTag F0315

Quality of Life and Care Deficiencies

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.

Corrected: Aug 27, 2017
Medium - PatternTag F0371

Nutrition and Dietary Deficiencies

Store, cook, and serve food in a safe and clean way.

Corrected: Aug 27, 2017
Medium - PatternTag F0431

Pharmacy Service Deficiencies

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Corrected: Aug 27, 2017
Medium - PatternTag F0166

Resident Rights Deficiencies

Try to resolve each resident's complaints quickly.

Corrected: Aug 27, 2017
Medium - PatternTag F0274

Resident Assessment and Care Planning Deficiencies

Review or revise the resident's care plan after any major change in physical or mental health.

Corrected: Aug 27, 2017
Medium - PatternTag F0371

Nutrition and Dietary Deficiencies

Store, cook, and serve food in a safe and clean way.

Corrected: Aug 27, 2017
Medium - PatternTag F0431

Pharmacy Service Deficiencies

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.

Corrected: Aug 27, 2017
Medium - PatternTag F0514

Administration Deficiencies

Keep accurate, complete and organized clinical records on each resident that meet professional standards.

Corrected: Aug 27, 2017
Medium - PatternTag F0166

Resident Rights Deficiencies

Try to resolve each resident's complaints quickly.

Corrected: Aug 27, 2017
Medium - PatternTag F0274

Resident Assessment and Care Planning Deficiencies

Review or revise the resident's care plan after any major change in physical or mental health.

Corrected: Aug 27, 2017
Medium - PatternTag F0315

Quality of Life and Care Deficiencies

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.

Corrected: Aug 27, 2017

Understanding Deficiencies

Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).

Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.

Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →

Penalties & Enforcement

No penalties or payment denials in the past 3 years

Key Highlights

🛏
Beds Available
Approximately 14 beds potentially available
🏢
Part of Healthcare Chain
AUTUMN LAKE HEALTHCARE

Frequently Asked Questions

What is the quality rating for AUTUMN LAKE HEALTHCARE AT SPA CREEK?

AUTUMN LAKE HEALTHCARE AT SPA CREEK has an overall CMS rating of 3 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.

How many beds does this facility have?

AUTUMN LAKE HEALTHCARE AT SPA CREEK has 130 certified beds. The facility averages 116 residents per day, with an occupancy rate of approximately 89%.

What type of ownership does this facility have?

This facility is for profit - limited liability company owned. It is part of the AUTUMN LAKE HEALTHCARE network.

How can I contact AUTUMN LAKE HEALTHCARE AT SPA CREEK?

You can call AUTUMN LAKE HEALTHCARE AT SPA CREEK at (410)269-5100. The facility is located at 35 MILKSHAKE LANE, ANNAPOLIS, MD 21403.

What should I look for when choosing a nursing home?

When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.

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