35 Milkshake Lane, Annapolis, MD 21403 · Anne Arundel County · (410) 269-5100
130 certified beds, about 116 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1994
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215258 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on August 6, 2025, inspectors cited 18 health deficiencies (the Maryland average is 17, the national average 9.2).
Of 73 health citations since November 2018, 1 was rated as actual harm or immediate jeopardy to residents (1 immediate jeopardy).
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.47 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.54 of those hours.
52.5% of nursing staff left within the year CMS measured (Maryland average 40.2%).
CMS links it to Autumn Lake Healthcare, an affiliated group of 59 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 73 health citations on file.
Inspectors wroteBased on observation, record reviews and interviews, it was determined that the facility failed to develop/implement care plans for Residents. This was found to be evident for 5 (Resident # 16, #8, #60, #107, and #82) out of 25 Residents reviewed for care plans during the recertification survey.
Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to ensure staff provided services that met professional standards of practice. This was found to be evident for 5 (Resident #55, #131, #81, #142, and #96) out of 5 Residents reviewed for Services Meet Professional Standards of Practice during the recertification survey.
Inspectors wroteBased on observations, interviews and record reviews it was determined that the facility failed to ensure medications were administered with a 5% or less error rate. This was found to be evident for 12 errors out of 31 medication administration opportunities that resulted in an error rate of 38.71% during the recertification survey.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure that 1) the medication refrigerator was used to store only medications and 2) medications were stored properly in the medication carts. This was found to be evident for 1 (1st floor medication refrigerator) out of 2 medication refrigerators and 3 out of 4 medication carts observed for medication storage during the recertification survey.
Inspectors wroteBased on observations, facility staff interviews and surveyor record review, it was determined that the facility failed to maintain proper sanitation for storage of food on the nursing units and in the kitchen. This was found to be evident on 2 out of 3 nursing units and on the initial and follow-up tours of the kitchen during review of food storage and sanitation.
Inspectors wroteBased on record reviews and interview, it was determined that the facility failed to ensure 1) immunization education was provided to Residents and 2) an immunization was offered. This was found to be evident for 5 (Resident #33, #14, #16, #10, and #58) out of 5 Residents reviewed for immunizations during the recertification survey.
Inspectors wroteBased on surveyor observations, staff interviews and surveyor record reviews, it was determined that the facility failed to ensure the dignity of Residents. This finding was found to be evident in 2 (Resident #99 and #143) out of 2 Residents reviewed for Resident Rights.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide access to resident's funds during non-banking hours. This was found to be evident for 1 (Resident #41) out of 1 resident reviewed for personal funds.
Inspectors wroteBased on surveyor observations and facility staff interview it was determined that the facility failed to provide a safe, clean, comfortable homelike environment for Residents. This finding was found to be evident in 5 (Resident #5, #9, #99, #119 and #141) out of 5 Resident rooms reviewed for safe/clean/comfortable/homelike environment.
Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to ensure that the required parties were notified appropriately. This was found to be evident for 1 (Resident #16) out of 3 Residents reviewed for discharge during the recertification survey.
Inspectors wroteBased on observation, Resident and staff interviews and surveyor record review it was determined that the facility failed to accurately complete a Minimum Data Set (MDS) assessment on a Resident. This finding was found to be evident in 1 (Resident #82) out of 2 Residents reviewed for accuracy of MDS assessments.
Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to ensure care plan meetings were held in a timely manner. This was found to be evident for 1 (Resident #3) out of 1 Resident reviewed for care plan meetings during the re-certification survey.
Inspectors wroteBased on observation, interviews and record reviews it was determined that the facility failed to ensure Activities of Daily Living (ADL) were provided to a Resident. This was found to be evident for 2 (Resident #108 and #42) out of 5 Residents reviewed for ADL care during the recertification survey.
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to follow the physician orders for the management of constipation. This was evident for 1 (Resident #33) of 1 resident reviewed for constipation/ diarrhea during the recertification survey.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure Pharmacy Recommendations were 1) reviewed in a timely manner and 2) implemented accurately. This was found to be evident for 2 (Resident #60 and #9) out of 5 Residents reviewed for Medication Regimen Review during the recertification survey. This deficient practice was identified as past non-compliance.
Inspectors wroteBased on observation, record review and interview, it was determined that the facility failed to provide adequate monitoring for resident on anticoagulant medication. This was evident for 1 (Resident #33) of 2 residents reviewed for Anticoagulants during the recertification survey.
Inspectors wroteBased on observation and interviews it was determined that the facility failed to ensure staff practiced infection control. This was evident for 2 (LPN # 4 & LPN#11) staff out of 2 staff observed for infection control during the recertification survey.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure the activities program was directed by a qualified professional. This deficiency was identified during the review of the activities program conducted during the survey and has the potential to affect all residentsThe
Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure equipment was operational. This was found to be evident for 1 out of 1 observation for the door alarm operating system during the recertification survey.
Inspectors wrote3. On 6/3/25 at 8:40 AM the following environmental observations were made on 3 of the 4 hallways on the second-floor nursing unit: In room [ROOM NUMBER]B there were (2) areas on the night stand where the laminate was missing on the right top and the left lower corner. In the bathroom the toilet riser frame had rust in the front middle bar and on the legs. In room [ROOM NUMBER]A laminate was peeling off the bed's footboard approximately 6 inches on the left side and on the right corner. In room [ROOM NUMBER]B the vinyl on the left wheelchair armrest was cracked on the front side. The laminate on the dresser was peeling on the third drawer on the right and left side. There was no handle on the drawer. In room [ROOM NUMBER]A the laminate on the over the bed tray table was missing about 5 inches by 4 inches with the particle board exposed. [...]
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#26, #18, #22, #33) of 38 residents reviewed during a complaint survey.
Inspectors wroteBased on observation and staff interview, it was determined that the facility staff failed to follow infection control practices and guidelines to prevent the development and transmission of disease. This was evident on 1 of 2 nursing units observed during a complaint survey.
Inspectors wroteBased on review of the facility's and vendor's pest control logs, observations and interviews, it was determined that the facility failed to maintain an effective pest control program. This was evident for kitchen, nurses stations, pantries, and 26 of 70 resident rooms during a complaint survey.
Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to treat each resident in a dignified manner by standing over a resident while feeding the resident and speaking to a resident in a harsh tone. This was evident for 3 (#37, #9, #38) of 38 residents reviewed during a complaint survey.
Inspectors wroteBased on reviews of facility reported incidents and interview, it was determined the facility failed to report allegations of abuse to the regulatory agency, the Office of Health Care Quality (OHCQ) within 2 hours of the allegation. This was evident for 1 (Resident #13) of 17 residents reviewed for facility reported incidents during a complaint survey.
Inspectors wroteBased on review of complaint, medical record review, and staff interview, it was determined the facility failed to properly perform neuro checks after a fall for residents (Resident #33 and #34). This was evident for 2 of 22 residents reviewed during a complaint survey.
Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to provide treatment/services to prevent/heal pressures ulcers. This is evident for 2 (Resident #15 and #16) of 4 residents reviewed for pressure ulcers during a complaint survey.
Inspectors wroteBased on review of a complaint, record review, and interview, it was determined the facility failed to provide timely medication to meet the needs of the residents. This was evident for 1 (#17) of 22 residents reviewed for complaints during a complaint survey.
Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to obtain outside services for residents in a timely manner. This was evident for 2 (Resident #15 and #16) of 22 residents reviewed for complaints during a complaint survey.
Inspectors wroteBased on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 1 (Resident #16) of 22 residents reviewed for complaints during a complaint survey.
Inspectors wroteBased on observation, medical record review and interviews, it was determined that the facility staff failed to promote care for residents in a manner and in an environment that maintained or enhanced the resident's dignity and respect. This was evident in 3 (residents #54, #66, #459) of 12 residents observed for dignity during the annual survey.
Inspectors wroteBased on observation and interview, the facility failed to accommodate the needs of residents by failing to ensure resident meal trays reflect the resident-completed meal slips, (Residents #6, #14, #18, #27, #36, #44, #46, #61, #63, #65, #67, #69, #82, #147, #203). This was evident in 15 of 91 residents reviewed during the facility's annual survey.
Inspectors wroteBased on record reviews and staff interviews it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS) assessments which should have included the resident's participation in the resident interviews, and failed to complete MDS assessments timely. This was evident for 8 of 12 residents reviewed for assessment reviews during an annual survey (Residents #12, #23, #53, #66, #67, #89, #142, and #452) . The Findings Include: The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents' progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. [...]
Inspectors wroteBased on record reviews and staff interviews it was determined that the facility failed to use the instructions from Resident Assessment Instrument (RAI) to reflect resident's status accurately as of the Assessment Reference Date (ARD). This was found to be true for 5 of 6 residents (Residents #39, #86, #88, #452, and #303) reviewed for assessment accuracy during a annual survey. The Findings Include: The Resident Assessment Instrument (RAI) delineates the process that long term care facilities follow to screen residents, assess resident strengths and needs, plan for resident care delivery, and evaluate the residents progress and needs on an ongoing basis by returning to additional, periodic screening, assessment and planning throughout a resident admission. [...]
Inspectors wroteBased on medical record review and interview it was determined the facility failed to provide a written notice to a resident, responsible party, and/or family member with a reason why the room assignment was changed. This was evident in one (Resident#112) of 2 resident records reviewed for changed room assignments.
Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that a resident environment was homelike and maintained in an orderly manner. This was found to be evident for the 2nd floor of the facility and 1 of 91 residents (resident #9) observed during the facility's annual Medicare/Medicaid survey.
Inspectors wroteBased on review of the facility investigation; review of other pertinent documentation and interview with staff it was determined that the facility failed to protect resident #131 from and verbal abuse and protect residents from potential verbal abuse. This occurred in on 1 of 10 residents reviewed for abuse.
Inspectors wroteBased on record review and interviews it was determined the facility failed to protect residents from being forced to stay in their rooms by staff tying a sheet to the doorknob and outside corridor rail. This was evident in 2 (Resident #2 & #119) of 2 residents reviewed for involuntary seclusion.
Inspectors wroteBased on an administrative record review and interviews with facility staff, it was determined the facility failed to complete a thorough investigation into allegations of abuse. This was found to be evident for 3 of 91 residents (Resident # 8, #108 & #134) reviewed during the facility's annual Medicare/Medicaid survey.
Inspectors wroteBased on record reviews and staff interviews it was determined that the facility failed to: 1) complete Quarterly Minimum Data Set (MDS) assessments which should have included the resident's participation in the resident interviews and 2) failed to ensure that Quarterly MDS assessments were completed within the required time frame. This was evident for 18 of 20 residents (Residents # 8, # 18, # 21, # 27, # 34, # 38, # 39, # 40, # 46, # 54, # 61, # 63, # 76, # 78, # 79, # 86, # 88, and # 303) selected for assessment reviews during the survey. The Findings Include: The Minimum Data Set (MDS) is a standardized assessment tool that measures health status in nursing home residents. MDS assessments are completed Quarterly (every 3 months) or more often, depending on circumstances. An Assessment Reference Date (ARD) is the date that shows the end of the look back (observation) period. [...]
Inspectors wroteBased on medical record review and interviews with facility staff, the facility failed to update a resident's care plan after a change of status, and failed to consistently conduct quarterly care plan meetings. This was found to be evident for 5 of 91 residents reviewed during the facility's annual Medicare/Medicaid survey (Resident # 9, #48, #53 #122, and #144).
Inspectors wroteBased on observation and interview it was determined the facility failed to provide oral care in a timely manner to a resident dependent on activities of daily living care (ADL). This was evident in one (#78) of three residents reviewed for dependent ADL care.
Inspectors wroteBased on observations, interview with family and review of medical records it was determined that the facility staff failed to ensure residents are provided with activities that meet the resident's needs based on their assessment. This was evident for 1 out of 4 (R#453) residents reviewed for activities during the investigation stage of the long-term care survey.
Inspectors wroteBased on medical record review and interviews, the facility staff failed to administer medication according to a physician's order and failed to clarify a physician's order prior to administering oxygen. This was evidenced in 2 of 5 resident records reviewed for medication administration during a facility's annual survey (Resident #66 & #458).
Inspectors wroteBased on medical record review and interviews it was determined the facility failed to monitor a resident's weight who was identified as being at risk for weight loss. This was evident in one (#112) of one resident record reviewed for weight loss during the annual survey.
Inspectors wroteBased on record review and interviews it was determined the facility failed to maintain the daily staffing schedule for 18 months. This deficient practice was evident in one of the units observed during a facility's annual survey.
Inspectors wroteBased on record review and interview, the facility failed to provide necessary behavioral health services for the diagnosis of adjustment disorder (resident #352). This was found to be true for 1 of 96 residents reviewed during a facility's annual survey.
Inspectors wroteBased on observations, a review of the facility's policies and interviews of the facility's staff. it was determined that the facility failed to ensure that the medication refrigerator temperature logs were maintained, and the medication storage room was always locked. This was found to be evident during observations made during the facility's annual Medicare/Medicaid survey.
Inspectors wroteBased on observation, record review, and interview it was determined the facility staff failed to monitor the temperature of the refrigerator located in the pantry located on the Unit Lighthouse. This deficient practice has the potential to affect all the residents who reside in Unit Lighthouse.
Inspectors wroteBased on medical record review and interview, the facility failed to provide an accurate matrix for all current residents. This deficient practice was found during a facility's annual survey.
Inspectors wroteBased on medical record review and interview it was determined the facility failed to maintain medical records according to professional standards. This was evident in one (#66) resident of thirteen medical records reviewed during the annual survey.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff. This deficient practice has the potential to affect all the residents who reside in the unit Lighthouse.
Inspectors wroteBased on administrative and medical record review and staff interview it was determined the facility failed to ensure residents were free of significant medication errors when two nurses administered five times the prescribed amount of Morphine Sulfate within a six and one-half hour period with the facility failed to thoroughly investigate the systems failures that contributed to the error and failed to ensure staff clarified an order for an antibiotic prior to administration. This was evident for 2 of 5 residents (Resident #103 and #11) reviewed for unnecessary medications and during the observation of medication pass for 1 of 4 residents (Resident #90) observed during the facility's annual survey. [...]
Inspectors wroteBased on administrative and medical record review and staff interview it was determined the facility failed to: 1. report a subnormal temperature to the physician and monitor the resident (Resident #255) after noting the change in condition and 2. failed to ensure initial smoking and elopement evaluations accurately reflected a resident's (Resident #67) diagnosis of dementia. This was evident for 2 of 3 residents reviewed for quality of care during this annual survey.
Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to establish and maintain a system for ensuring accuracy in weight measurements for a nutritionally compromised resident, and failed to ensure that physician ordered weekly weights were obtained and recorded as ordered. This was evident in 2 of 5 residents (Resident #24 and #11) reviewed for nutrition during this annual survey.
Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to ensure that there was not greater than 14 hours between the residents receiving their last meal for the evening and the next scheduled meal. This was found to be evident during the facility's annual survey.
Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that sanitary conditions were maintained in the kitchen and food was stored properly. This was found to be evident during an initial tour of the facility during the facility's annual survey.
Inspectors wroteBased on interviews with residents and staff and a review of resident council meeting minutes it was determined the facility failed to give adequate responses to grievances that were presented by the resident council. This was found to be evident during a resident council meeting that was conducted during the facility's annual survey.
Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure a chair alarm was only used when there was a physician order for the use of the alarm. This was found to be evident for 1 out of the 2 residents (Resident #35) reviewed for the use of restraints during the survey.
Inspectors wroteBased on medical record review and interviews it was determined that the facility failed to have an effective system in place to ensure residents and responsible parties were provided written notification regarding the reason for a hospital transfer, the location to which the resident was transferred, a statement of appeal rights or the contact information for the ombudsman. This was found to be evident for 1 out of 5 residents (Resident #11) reviewed for hospitalization during the investigative portion of the survey. On 10/30/18 review of Resident #11's medical record revealed the resident had been discharged to the hospital in July 2018 with a readmission several days later. Further review of the medical record failed to reveal any documentation that the resident or a responsible party was provided any information in writing in regard to the hospital transfer. [...]
Inspectors wroteBased on on medical record review, interview and review of recent facility discharge practices, it was determined that the facility failed to provide residents and or the resident representative (RP) with the proper paper documentation of the facility's bed-hold policy when a discharge to the hospital occurred, and failed to ensure correct information was shared when contact was made regarding the bed-hold policy. This was evident for 3 of 3 resident records (Resident #13, #47 and # 11) reviewed regarding planned and unplanned hospitalizations.
Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure accurate Minimum Data Set (MDS) assessments as evidenced by 1. failure to assess the use of a chair alarm; 2. failure to assess a resident who is dependant on g-tube feeding for nutrition as being totally dependant for eating. and 3. failed to identify a resident's weight loss and therefore, code a significant weight loss on the MDS correctly. This was found to be evident for 3 out of the 29 residents reviewed (Resident #35, #74 and # 88) during the survey.
Inspectors wroteBased on medical record review and interviews with facility staff it was determined the facility failed to complete a baseline care plan on a resident admitted with a Deep Tissue Injury (DTI), a pressure related injury to subcutaneous tissue under the skin. This was found to be evident for 1 resident (Resident #253) reviewed for pressure ulcers during the facility's annual survey.
Inspectors wrote3. Failed to ensure care plans were updated to reflect current functional maintenance program (FMP) interventions: A. On 11/1/18 review of Resident #26's medical record revealed the resident was admitted in 2016 and whose diagnoses included stroke with right sided weakness, high blood pressure, diabetes and lung disease. Review of the 8/16/18 Minimum Data Set (MDS) assessment revealed the resident was cognitively intact as evidenced by a Brief Interview for Mental Status score of 15 out of 15; with clear speech and ability to understand and make self understood verbally. Further review of the 8/16/18 MDS revealed the resident was not steady during transfers and walking, and was only able to stabilize with staff assistance. On 10/29/18 at 11:25 AM the resident reported a concern regarding his/her toe related to poor circulation. [...]
Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to update the care plan that addressed: 1. the risk for fluid volume excess for a resident and 2. the use of a gait belt for a resident with a history of falls. This was evident for 2 residents (Resident #24 and #252) reviewed for care plan updates during this annual survey.
Inspectors wroteBased on interview and review of medical records it was determined that the facility failed to ensure staff reported when a resident sustained a fall. This was found to be evident for 1 out of 6 residents (Resident #26) reviewed for falls during the survey.
Inspectors wroteBased on review of employee files and interview it was determined that the facility failed to have a system in place to ensure annual evaluations and required dementia training had been completed by the geriatric nursing assistants (GNAs). This was found to by evident for 3 out of the 3 GNAs (GNA's #20, #21 and #22) reviewed for annual evaluations.
Inspectors wroteBased on administrative and medical record review and staff interview it was determined the facility failed to promptly dispose of Morphine Sulfate, prescribed for Resident #103 upon the resident's death. This was evident for 1 of 3 residents reviewed for narcotics accountability during this annual survey.
Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure monthly pharmacist reviews were completed for each resident. This was found to be evident for 1 out of 6 residents (Resident #11) selected for unnecessary medication review. The facility also failed to respond to pharmacy irregularities that were identified by the pharmacy. This was found to be evident for 1 resident (Resident # 49) reviewed.
Inspectors wrote2. Review of the medical record for Resident #79 on 10/30/18 at 10:00 AM revealed diagnoses including Parkinson's disease and chronic pain syndrome. Further review of Resident #79's medical record revealed physician orders on 10/3/18 for Percocet to be administered every 6 hours as needed for moderate to severe pain (4-10 on a pain score). Review of Resident #79's medication administration record (MAR) revealed administration of the Percocet 25 of 29 days in October 2018, one to four times a day. According to the MAR the medication was documented as E for effective. A closer look at the residents nursing notes revealed that the E for effectiveness was not documented or assessed within an hour after the medication was administered. [...]
Inspectors wroteBased on observation and medical record review it was determined that the facility failed to administer medications and maintain an error rate of less than 5% by following physician orders. This was evident during the observation of medication pass by 4 nurses and 5 residents and 30 medication opportunities.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to 1. ensure medical records were accurately documented as evidenced by failure to ensure staff did not document services which were not provided, and 2. document evidence of ongoing monitoring of a resident (Resident #103) with a change in condition that required the administration of narcotic pain medication. This was found to be evident for 2 out of 29 residents (Resident #26 and Resident #103) reviewed during the survey.
Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to have an effective system in place to ensure influenza consents were obtained from the appropriate party and administration of the influenza vaccine were administered to newly admitted residents. This was found to be evident for 1 out of the 5 resident's (Resident #151) reviewed for administration of the influenza vaccine.
27 fire safety citations on file: 11 on August 6, 2025, 16 on February 3, 2023.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Maryland | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.47 | 3.87 | 3.86 |
| Registered nurses | 0.54 | 0.84 | 0.69 |
| All nursing staff on weekends | 3.13 | 3.47 | 3.42 |
| Nurse aides | 1.71 | ||
| Licensed practical nurses | 1.22 | ||
| Nursing staff turnover (share who left in a year) | 52.5% | 40.2% | 45.8% |
| Registered nurse turnover | 52.6% | 38.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.18 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.60 on weekdays and 3.13 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 13.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.72 in April to June 2025 to 3.47 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.47 | 0.54 | 3.60 | 3.13 | 13.2% | 0 of 90 | 116 |
| Oct to Dec 2025 | 3.59 | 0.53 | 3.72 | 3.26 | 14.7% | 0 of 92 | 114 |
| Jul to Sep 2025 | 3.78 | 0.53 | 3.93 | 3.42 | 21.1% | 0 of 92 | 114 |
| Apr to Jun 2025 | 3.72 | 0.51 | 3.86 | 3.39 | 30.1% | 0 of 91 | 117 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Maryland, Jan to Mar 2026 | 3.73 | 0.74 | 3.88 | 3.34 | 8.0% | 0.1% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Maryland, all employers | |||
| CNAs (nursing assistants) | $20.79 | $18.46 to $22.00 | 27,720 |
| LPNs and LVNs | $35.89 | $31.40 to $38.30 | 9,560 |
| Registered nurses | $47.98 | $40.26 to $51.61 | 52,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Maryland | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 22.6 | 20.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.5 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.4 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 2.1 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.0 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 25.1 | 22.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.1 | 5.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 1.9 | 13.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 22.9 | 21.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 4.9 | 9.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.7 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Autumn Lake Healthcare at Spa Creek's Medicare short-stay residents. On returning residents home or to the community, CMS rates it better than the national rate (62.3% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
62.3% this home
Better than the national rate
US median of homes 51.5% · Maryland: 90 better, 29 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 650 eligible stays.
16.1% this home
Worse than the national rate
US median of homes 10.7% · Maryland: 0 better, 41 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 658 eligible stays.
7.3% this home
No different from the national rate
US median of homes 7.1% · Maryland: 5 better, 6 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 389 eligible stays.
75.5% this home
Median of homes: Maryland61.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 241 residents counted.
1.1% this home
Median of homes: Maryland0.4% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 363 residents counted.
1.4% this home
Median of homes: Maryland2.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 363 residents counted.
97.7% this home
Median of homes: Maryland98.1% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 266 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: 35 MILKSHAKE OPCO LLC. CMS links this home to Autumn Lake Healthcare, a group of 59 nursing homes averaging 2.9 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| 35 Milkshake Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 05/01/2021 |
| Stern, Aryeh | Indirect ownership interest | Individual | 05/01/2021 | |
| McInerney, Ellen | Operational/managerial control | Individual | 08/01/2022 | |
| Neel, Elizabeth | Operational/managerial control | Individual | 07/27/2021 | |
| Schwartz, Mark | Operational/managerial control | Individual | 05/01/2021 | |
| Eidlisz, Solomon | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 03/13/2025 | |
| Gluck, Rivka | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 03/27/2025 | |
| Accurate Staffing LLC | Adp of the SNF | Organization | 05/01/2021 | |
| Brand Sonnenschine LLP | Adp of the SNF | Organization | 05/01/2021 | |
| McInerney, Ellen | Adp of the SNF | Individual | 08/01/2022 | |
| Neel, Elizabeth | Adp of the SNF | Individual | 07/27/2021 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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