Cycle 1
Health 2024-08-16 · Fire 2024-08-16
8 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Frederick, MD
Autumn Lake Healthcare At Braddock Heights
5-star overall rating with 4-star inspections with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
6012 Jefferson Boulevard, Frederick, MD
(301) 371-7160
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
65
Certified beds
Average residents
57
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1989-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.90
Registered nurse staffing
LPN hours / resident day
0.82
Licensed practical nurse staffing
Aide hours / resident day
1.59
Nurse aide staffing
Weekend hours
3.10
Weekend nurse staffing
RN turnover
46%
Annual RN turnover
Total nurse turnover
55%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
1.3
0.9 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.2
0.3 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.9%
8.1 pts better
|
93.4%
6.6 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 | 1.1% |
2.3%
1.2 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 12.4% |
21.4%
9 pts better
|
11.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 11.1% |
5.7%
5.4 pts worse
|
5.4%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.5% |
16.1%
8.4 pts worse
|
19.6%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
15.3%
9.2 pts worse
|
16.7%
7.8 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 | 20.9% |
26.6%
5.7 pts better
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.6% |
22.9%
8.7 pts worse
|
14.9%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
25.4%
1.7 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.8% |
6.3%
0.5 pts better
|
5.1%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
78.4%
13.9 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.1% |
9.9%
3.2 pts worse
|
12.0%
1.1 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.4% |
1.3%
1.1 pts worse
|
1.6%
0.8 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.0% |
80.6%
10.4 pts better
|
79.7%
11.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.8% |
21.2%
8.4 pts better
|
23.9%
11.1 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-27 · Fire 2019-06-27
18 health deficiencies
Top issue: Resident Rights (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-02-27 · Fire 2018-02-27
31 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-16
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-10
F · Potential for more than minimal harm
2024-08-16
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-16
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-08-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-10
D · Potential for more than minimal harm
2019-06-27
K227 · Egress Deficiencies
Fire Safety
Have ramps, exits, fire escape ladders, steps, and areas of refuge that meet safety requirements.
Corrected 2019-08-03
D · Potential for more than minimal harm
2019-06-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2019-07-24
D · Potential for more than minimal harm
2019-06-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-07-24
C · Minimal harm
2019-06-27
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Not marked corrected
C · Minimal harm
2019-06-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-25
E · Potential for more than minimal harm
2018-02-27
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-03-24
D · Potential for more than minimal harm
2018-02-27
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2018-03-24
B · Minimal harm
2018-02-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-03-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-23
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Not marked corrected
D · Potential for more than minimal harm
2026-01-23
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
D · Potential for more than minimal harm
2026-01-23
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
E · Potential for more than minimal harm
2024-08-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-04
E · Potential for more than minimal harm
2024-08-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-16
F585 · Resident Rights Deficiencies
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 2024-10-04
D · Potential for more than minimal harm
2024-08-16
F625 · Resident Rights Deficiencies
Health
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 2024-10-04
D · Potential for more than minimal harm
2024-08-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-16
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2024-10-04
D · Potential for more than minimal harm
2024-08-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-10-04
D · Potential for more than minimal harm
2019-06-27
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F578 · Resident Rights Deficiencies
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 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F657 · Resident Assessment and Care Planning Deficiencies
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 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F756 · Pharmacy Service Deficiencies
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 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F761 · Pharmacy Service Deficiencies
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 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-08-07
D · Potential for more than minimal harm
2019-06-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2019-08-07
F · Potential for more than minimal harm
2018-02-27
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2018-04-09
F · Potential for more than minimal harm
2018-02-27
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2018-04-09
F · Potential for more than minimal harm
2018-02-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-04-09
F · Potential for more than minimal harm
2018-02-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2018-04-09
F · Potential for more than minimal harm
2018-02-27
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-04-09
F · Potential for more than minimal harm
2018-02-27
F922 · Environmental Deficiencies
Health
Have enough backup water supply for essential areas of the nursing home.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F584 · Resident Rights Deficiencies
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 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F657 · Resident Assessment and Care Planning Deficiencies
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 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F756 · Pharmacy Service Deficiencies
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 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F758 · Pharmacy Service Deficiencies
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 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-04-09
E · Potential for more than minimal harm
2018-02-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F578 · Resident Rights Deficiencies
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 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F761 · Pharmacy Service Deficiencies
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 2018-04-09
D · Potential for more than minimal harm
2018-02-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-04-09
Penalties and ownership
What sits behind the stars
Ownership
6012 Jefferson Boulevard Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
As Family Vb Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
M Meisels Family Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Mclaurin, Lisa
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Wah, John
Operational/Managerial Control · Individual
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