Cycle 1
Health 2025-03-17 · Fire 2025-03-17
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Gambrills, MD
Autumn Lake Healthcare At Waugh Chapel
5-star overall rating with 4-star inspections with 9 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1221 Waugh Chapel Road, Gambrills, MD
(410) 923-2020
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
105
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1983-07-01
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
1.45
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.82
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
2.06
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.74
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,539
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9925
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.96
Baseline 17.24% · Performance 18.20% · Measure score 6.96 · Achievement 6.96 · Improvement 0
Healthcare-associated infections
6.33
Baseline 6.60% · Performance 5.94% · Measure score 6.33 · Achievement 6.33 · Improvement 3.61
Total nurse turnover
2.52
Baseline 69.08% · Performance 55.73% · Measure score 2.52 · Achievement 1.95 · Improvement 2.52
Adjusted total nurse staffing
0
Baseline 3.24 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.21% |
10.72%
2.5 pts worse
|
Worse than the National Rate · Eligible stays 873 · Observed rate 12.6% · Lower 95% interval 10.91% |
| Discharge to community | 66.46% |
50.57%
15.9 pts better
|
Better than the National Rate · Eligible stays 866 · Observed rate 64.43% · Lower 95% interval 63.31% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 516 · Denominator 516 |
| Falls with major injury | 0.97% |
0.77%
0.2 pts worse
|
Numerator 5 · Denominator 516 |
| Discharge self-care score | 63.95% |
53.69%
10.3 pts better
|
Numerator 243 · Denominator 380 |
| Discharge mobility score | 59.47% |
50.94%
8.5 pts better
|
Numerator 226 · Denominator 380 |
| Pressure ulcers or injuries, new or worsened | 1.74% |
2.29%
0.6 pts better
|
Numerator 9 · Denominator 516 · Adjusted rate 1.67% |
| Healthcare-associated infections requiring hospitalization | 5.94% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 533 · Observed rate 4.88% · Lower 95% interval 4.38% |
| Staff COVID-19 vaccination coverage | 2.4% |
8.2%
5.8 pts worse
|
Numerator 3 · Denominator 125 |
| Staff flu vaccination coverage | 88.97% |
42%
47 pts better
|
Numerator 121 · Denominator 136 |
| Discharge function score | 61.84% |
56.45%
5.4 pts better
|
Numerator 235 · Denominator 380 |
| Transfer of health information to provider | 99.08% |
95.95%
3.1 pts better
|
Numerator 108 · Denominator 109 |
| Transfer of health information to patient | 97.67% |
96.28%
1.4 pts better
|
Numerator 377 · Denominator 386 |
| Resident COVID-19 vaccinations up to date | 32.22% |
25.2%
7 pts better
|
Numerator 87 · Denominator 270 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.8 · Expected 2.2 · 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 0.7 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
2.3%
1.7 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.0% |
21.4%
10.4 pts better
|
11.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 20.0% · Q3 10.5% · Q4 5.1% · 4Q avg 11.0% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
5.7%
1.3 pts worse
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 11.1% · Q3 5.6% · Q4 2.9% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.2% |
16.1%
1.1 pts worse
|
19.6%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 18.9% · Q3 19.4% · Q4 19.4% · 4Q avg 17.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.5% |
15.3%
1.8 pts better
|
16.7%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 12.5% · Q3 13.8% · Q4 16.1% · 4Q avg 13.5% · 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 need for help with daily activities has increased | 23.8% |
22.9%
0.9 pts worse
|
14.9%
8.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 34.4% · Q3 12.9% · Q4 15.2% · 4Q avg 23.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.5%
0.9 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.7% |
25.4%
1.7 pts better
|
19.8%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 24.6% · Q3 25.5% · Q4 26.3% · 4Q avg 23.7% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.3%
0.8 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 6.0% · Q3 5.2% · Q4 3.8% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
78.4%
20.1 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 98.3% · Q3 98.2% · Q4 98.2% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
9.9%
1.8 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 10.6% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.4% · Q2 1.1% · Q3 2.0% · Q4 2.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 96.4% |
80.6%
15.8 pts better
|
79.7%
16.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 96.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.5% |
21.2%
1.7 pts better
|
23.9%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.5% · Observed 18.3% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-02-03 · Fire 2020-02-03
11 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
5 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-08-01 · Fire 2018-08-01
5 health deficiencies
Top issue: Quality of Life and Care (2 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
2025-03-17
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-17
K525 · Services Deficiencies
Fire Safety
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-02
F · Potential for more than minimal harm
2025-03-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-03-17
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-17
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 2025-05-02
D · Potential for more than minimal harm
2025-03-17
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-05-02
E · Potential for more than minimal harm
2020-02-03
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2020-08-27
D · Potential for more than minimal harm
2020-02-03
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-08-27
D · Potential for more than minimal harm
2020-02-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-08-27
D · Potential for more than minimal harm
2020-02-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-08-27
D · Potential for more than minimal harm
2020-02-03
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2020-08-27
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-30
E · Potential for more than minimal harm
2025-03-17
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 2025-04-23
D · Potential for more than minimal harm
2025-03-17
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 2025-04-23
D · Potential for more than minimal harm
2025-03-17
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 2025-04-23
D · Potential for more than minimal harm
2025-03-17
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 2025-04-23
D · Potential for more than minimal harm
2025-03-17
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 2025-04-23
D · Potential for more than minimal harm
2025-03-17
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 2025-04-23
D · Potential for more than minimal harm
2025-03-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-23
D · Potential for more than minimal harm
2025-03-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-23
E · Potential for more than minimal harm
2020-02-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-03-07
E · Potential for more than minimal harm
2020-02-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-03-07
E · Potential for more than minimal harm
2020-02-03
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 2020-03-07
E · Potential for more than minimal harm
2020-02-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-03
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 2020-03-07
D · Potential for more than minimal harm
2020-02-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-03
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 2020-03-07
D · Potential for more than minimal harm
2020-02-03
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 2020-03-07
D · Potential for more than minimal harm
2020-02-03
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-03
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-03-07
D · Potential for more than minimal harm
2020-02-03
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 2020-03-07
D · Potential for more than minimal harm
2018-08-01
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 2018-09-13
D · Potential for more than minimal harm
2018-08-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-09-13
D · Potential for more than minimal harm
2018-08-01
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2018-09-13
D · Potential for more than minimal harm
2018-08-01
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 2018-09-13
D · Potential for more than minimal harm
2018-08-01
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-09-13
Penalties and ownership
What sits behind the stars
Ownership
1221 Waugh Chapel Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
A&R Stern Family Md1 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hefter, Tzvi
Operational/Managerial Control · Individual
Ryan, Jacqueline
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Autumn Lake Healthcare At Crofton
Crofton, MD
4-star overall rating with 3-star inspections with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Fairfield Nursing & Rehabilitation Center
Crownsville, MD
2-star overall rating with 2-star inspections with $51,597 in total fines with 33 recent health deficiencies with 31 fire-safety deficiencies in the latest cycle
#3
Complete Care At Severna Park LLC
Severna Park, MD
2-star overall rating with 2-star inspections with 35 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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