Cycle 1
Health 2024-12-06 · Fire 2024-12-06
10 health deficiencies
Top issue: Nutrition and Dietary (6 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Silver Spring, MD
Autumn Lake Healthcare At Silver Spring
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
2501 Musgrove Road, Silver Spring, MD
(301) 890-5552
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
148
Certified beds
Average residents
137
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1990-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
60 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.61
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.27
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,557
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.47
Composite VBP score used to determine payment impact.
Payment multiplier
0.9924
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.87
Baseline 19.14% · Performance 20.57% · Measure score 1.87 · Achievement 1.87 · Improvement 0
Healthcare-associated infections
2.99
Baseline 6.49% · Performance 6.94% · Measure score 2.99 · Achievement 2.99 · Improvement 0
Total nurse turnover
10
Baseline 20.00% · Performance 15.62% · Measure score 10 · Achievement 10 · Improvement 9
Adjusted total nurse staffing
0.93
Baseline 3.78 hours · Performance 3.34 hours · Measure score 0.93 · Achievement 0.93 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.47% |
10.72%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 244 · Observed rate 12.7% · Lower 95% interval 9.67% |
| Discharge to community | 17.16% |
50.57%
33.4 pts worse
|
Worse than the National Rate · Eligible stays 210 · Observed rate 11.9% · Lower 95% interval 12.41% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.32% |
95.27%
4 pts better
|
Numerator 146 · Denominator 147 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 147 |
| Discharge self-care score | 42.39% |
53.69%
11.3 pts worse
|
Numerator 39 · Denominator 92 |
| Discharge mobility score | 43.48% |
50.94%
7.5 pts worse
|
Numerator 40 · Denominator 92 |
| Pressure ulcers or injuries, new or worsened | 2.05% |
2.29%
0.2 pts better
|
Numerator 3 · Denominator 146 · Adjusted rate 1.6% |
| Healthcare-associated infections requiring hospitalization | 6.94% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 156 · Observed rate 6.41% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 95.56% |
8.2%
87.4 pts better
|
Numerator 129 · Denominator 135 |
| Staff flu vaccination coverage | 66.67% |
42%
24.7 pts better
|
Numerator 100 · Denominator 150 |
| Discharge function score | 47.83% |
56.45%
8.6 pts worse
|
Numerator 44 · Denominator 92 |
| Transfer of health information to provider | 97.96% |
95.95%
2 pts better
|
Numerator 48 · Denominator 49 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 68 · Denominator 68 |
| Resident COVID-19 vaccinations up to date | 56.52% |
25.2%
31.3 pts better
|
Numerator 39 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| 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 · Adjusted 0.7 · Observed 0.6 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
91.9%
2 pts better
|
93.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 97.3% · Q3 94.9% · Q4 92.6% · 4Q avg 93.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
96.6%
2.5 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
2.3%
1.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.4% |
21.4%
10 pts better
|
11.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 9.6% · Q3 7.5% · Q4 6.2% · 4Q avg 11.4% |
| Percentage of long-stay residents who lose too much weight | 4.6% |
5.7%
1.1 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.9% · Q3 4.5% · Q4 8.7% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.8% |
16.1%
5.3 pts better
|
19.6%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.4% · Q3 14.3% · Q4 9.6% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.8% |
15.3%
0.5 pts worse
|
16.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 15.2% · Q3 14.8% · Q4 18.3% · 4Q avg 15.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 28.6% |
26.6%
2 pts worse
|
16.3%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.7% · Q2 15.7% · Q3 28.8% · Q4 23.1% · 4Q avg 28.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.2% |
22.9%
2.3 pts worse
|
14.9%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 25.8% · Q3 24.5% · Q4 17.3% · 4Q avg 25.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.7%
0.6 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.6% · Q4 0.0% · 4Q avg 0.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.2% |
25.4%
3.2 pts better
|
19.8%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.8% · Q2 22.1% · Q3 29.4% · Q4 20.7% · 4Q avg 22.2% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
6.3%
1.6 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 10.0% · Q3 8.8% · Q4 6.5% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.0% |
78.4%
5.4 pts worse
|
81.7%
8.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 68.4% · Q2 74.3% · Q3 77.5% · Q4 71.2% · 4Q avg 73.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.3% |
9.9%
2.6 pts better
|
12.0%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.3% · Observed 7.2% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.3%
0.2 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.9% · Q3 2.2% · Q4 1.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.6% |
80.6%
1 pts worse
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.2% |
21.2%
2 pts worse
|
23.9%
0.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.2% · Observed 25.2% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-02 · Fire 2019-08-02
9 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-09-27 · Fire 2018-09-27
16 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-02-01
F · Potential for more than minimal harm
2024-12-06
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-02-01
F · Potential for more than minimal harm
2024-12-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-02-01
E · Potential for more than minimal harm
2024-12-06
K223 · Egress Deficiencies
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 2025-02-01
D · Potential for more than minimal harm
2024-12-06
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-06
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-01
D · Potential for more than minimal harm
2024-12-06
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-01
D · Potential for more than minimal harm
2019-08-02
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-09-17
C · Minimal harm
2019-08-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-09-17
B · Minimal harm
2019-08-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-09-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-04
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 2025-08-15
D · Potential for more than minimal harm
2025-08-04
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-08-18
F · Potential for more than minimal harm
2024-12-06
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 2025-01-31
F · Potential for more than minimal harm
2024-12-06
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 2025-01-31
F · Potential for more than minimal harm
2024-12-06
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-31
E · Potential for more than minimal harm
2024-12-06
F809 · Nutrition and Dietary Deficiencies
Health
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 2025-01-31
D · Potential for more than minimal harm
2024-12-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-31
D · Potential for more than minimal harm
2024-02-07
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 2024-03-08
D · Potential for more than minimal harm
2024-02-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-07
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-07
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 2024-03-08
E · Potential for more than minimal harm
2019-08-02
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 2019-09-11
D · Potential for more than minimal harm
2019-08-02
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2019-09-11
D · Potential for more than minimal harm
2019-08-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2019-09-11
D · Potential for more than minimal harm
2019-08-02
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 2019-09-11
D · Potential for more than minimal harm
2019-08-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-09-11
D · Potential for more than minimal harm
2019-08-02
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 2019-09-11
B · Minimal harm
2019-08-02
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-09-11
B · Minimal harm
2019-08-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-11
B · Minimal harm
2019-08-02
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 2019-09-11
E · Potential for more than minimal harm
2018-09-27
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2018-11-06
E · Potential for more than minimal harm
2018-09-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-11-06
E · Potential for more than minimal harm
2018-09-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-11-06
D · Potential for more than minimal harm
2018-09-27
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 2018-11-06
D · Potential for more than minimal harm
2018-09-27
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2018-11-06
D · Potential for more than minimal harm
2018-09-27
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 2018-11-06
D · Potential for more than minimal harm
2018-09-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-11-06
C · Minimal harm
2018-09-27
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2018-11-06
C · Minimal harm
2018-09-27
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2018-11-06
B · Minimal harm
2018-09-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-11-06
Penalties and ownership
What sits behind the stars
Ownership
2501 Musgrove Road Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
As Family Sd Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
M Meisels Family Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
2501 Musgrove Road Propco LLC
5% Or Greater Mortgage Interest · Organization
Ifelowo, Yetunde
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Fairland Center
Silver Spring, MD
2-star overall rating with 2-star inspections with 31 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Riderwood Village
Silver Spring, MD
5-star overall rating with 5-star inspections with 5 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
#3
Complete Care At Springbrook
Silver Spring, MD
4-star overall rating with 3-star inspections with 16 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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