18 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Silver Spring, MD
3-star overall rating with 3-star inspections with 18 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
901 Arcola Avenue, Silver Spring, MD
(301) 649-2400
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
151
Certified beds
Average residents
143
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.57
Registered nurse staffing
LPN hours / resident day
0.88
Licensed practical nurse staffing
Aide hours / resident day
1.97
Nurse aide staffing
Weekend hours
3.11
Weekend nurse staffing
RN turnover
37%
Annual RN turnover
Total nurse turnover
29%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.3 |
1.2
0.9 pts better
|
1.8
1.5 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.9%
7.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
2.3%
1.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 23.2% |
21.4%
1.8 pts worse
|
11.4%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.9% |
5.7%
2.8 pts better
|
5.4%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.6% |
16.1%
8.5 pts better
|
19.6%
12 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 26.3% |
15.3%
11 pts worse
|
16.7%
9.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 21.0% |
26.6%
5.6 pts better
|
16.3%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.0% |
22.9%
9.1 pts worse
|
14.9%
17.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.7%
0.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.5%
1.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.6% |
25.4%
0.2 pts worse
|
19.8%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
6.3%
1 pts better
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
78.4%
20.2 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 2.1% |
9.9%
7.8 pts better
|
12.0%
9.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.2% |
80.6%
18.6 pts better
|
79.7%
19.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 10.4% |
21.2%
10.8 pts better
|
23.9%
13.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Resident Rights (5 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Rights (7 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2026-02-12
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-12
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-02-12
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2026-02-12
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-12
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-08-14
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-08-14
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-14
Fire Safety
Install proper backup exit lighting.
Corrected 2024-08-14
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-14
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-14
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-14
Fire Safety
Meet other general requirements.
Corrected 2024-08-14
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-08-14
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-14
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-08-14
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-08-14
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-08-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-14
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-08-31
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-08-31
Fire Safety
Construct fire resistant interior walls.
Corrected 2019-08-31
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-08-31
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-08-31
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-16
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-16
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2026-02-16
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2026-02-16
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2026-02-16
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2026-02-16
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-16
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-16
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2026-02-16
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2026-02-16
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2026-02-16
Health
Provide activities to meet all resident's needs.
Corrected 2026-02-16
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2026-02-16
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-02-16
Health
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 2026-02-16
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2026-02-16
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2026-02-16
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2026-02-16
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-08-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-08-07
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-08-07
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-08-07
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-08-07
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-08-07
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-08-07
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-08-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-02-28
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-08-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-08-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-07
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-08-07
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-08-07
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-07
Health
Provide or obtain dental services for each resident.
Corrected 2024-08-07
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-07
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-07
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-10-25
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2019-10-25
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-10-25
Health
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 2019-10-25
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-10-25
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2019-10-25
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2019-10-25
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2019-11-21
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2019-11-21
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-11-21
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2019-11-21
Health
Respond appropriately to all alleged violations.
Corrected 2019-11-21
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2019-10-25
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-10-25
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-11-21
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2019-10-25
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2019-10-25
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-10-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-10-25
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-10-25
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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