7 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Clinton, MD
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
7520 Surratts Road, Clinton, MD
(301) 856-1660
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
180
Certified beds
Average residents
169
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1987-06-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.45
Registered nurse staffing
LPN hours / resident day
0.95
Licensed practical nurse staffing
Aide hours / resident day
2.01
Nurse aide staffing
Weekend hours
3.03
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.8% |
91.9%
0.1 pts worse
|
93.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 89.7% |
96.6%
6.9 pts worse
|
95.5%
5.8 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.3%
1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
21.4%
18.6 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.7%
0.4 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
16.1%
6 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 5.7% |
15.3%
9.6 pts better
|
16.7%
11 pts better
|
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 | 24.9% |
26.6%
1.7 pts better
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
22.9%
7.1 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
1.5%
0.2 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
25.4%
3.4 pts better
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
6.3%
0.2 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.8% |
78.4%
4.6 pts worse
|
81.7%
7.9 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
9.9%
2.8 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.5% |
80.6%
27.1 pts worse
|
79.7%
26.2 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.9% |
21.2%
2.7 pts worse
|
23.9%
About the same
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Resident Assessment and Care Planning (4 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-03
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-04-03
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-03
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2025-04-03
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-03
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 2025-04-03
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-04-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-13
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-01-13
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2020-01-13
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2020-01-13
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-13
Inspection history
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-02-04
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2026-02-04
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 2026-02-04
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-04
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-11-21
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-03-28
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-28
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-28
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-28
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-28
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2020-01-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2020-02-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2020-01-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-01-22
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-22
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-08-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2018-08-25
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 2018-08-25
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2018-08-25
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2018-08-25
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-08-25
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 2018-08-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2018-08-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-08-25
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-08-25
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-08-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-08-25
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-08-25
Health
Provide and implement an infection prevention and control program.
Corrected 2018-08-25
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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