Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Braddock Heights during CMS and state inspections, most recent first.
A resident with a degenerative neurological condition, dependent for bed mobility and personal care, was found in bed without their call light within reach, despite the care plan and GNA Kardex directing that the call light be kept accessible at all times due to fall risk and impaired mobility. During an observation, the resident reported being unable to reposition without assistance and voiced concerns about delayed call bell responses. The call device was later observed on a nightstand at the foot of the bed, out of the resident’s reach, indicating staff had not followed the documented interventions for maintaining the call light within reach.
Surveyors found that the facility failed to timely report one allegation of abuse and failed to report another allegation at all. In one case, a resident’s abuse allegation was reported to a staff member, but the NHA did not submit the report to the state agency within the required 2-hour window, despite documentation showing she was notified earlier than she claimed. In another case, a cognitively intact roommate reported that an agency GNA provided rough, abrupt care and spoke angrily to a severely cognitively impaired resident who required total assist with ADLs, but the NHA chose not to report the allegation after asking the reporting resident if they believed it was abuse and deciding it did not meet the definition of abuse.
The facility failed to thoroughly investigate several abuse allegations and to properly document law enforcement notification. In one case, a resident alleged a GNA was rough and hit her during care, but the investigation file lacked staff and resident witness statements, a statement from the alleged perpetrator, resident assessments, and complete reporting documentation. In another case, a resident reported that a staff member purposefully struck his arm and slapped his hand away while handling a urinal; although there were some interview summaries and a witness statement, there was no signed statement from the alleged perpetrator or documentation that such a statement was requested or refused. In a third case, involving a non-communicative resident, the file contained questionnaires but did not identify witnesses, and the records claimed the sheriff’s office was notified without providing objective details such as date/time, officer identity, or report number, and there was no signed statement from the staff member alleged to be involved or documentation of attempts to obtain one.
The facility failed to prevent resident-to-resident abuse involving several residents with cognitive impairments and behavioral issues. One resident with Down's syndrome was slapped by another resident due to noise disturbance, and later smacked another resident in the dining room. Another incident involved a resident with poor impulse control hitting his roommate, who retaliated. These incidents were confirmed by facility investigations and interviews, indicating a deficiency in protecting residents from abuse.
The facility's water management program was incomplete and not aligned with ASHRAE guidelines, posing a potential risk for Legionnaire's disease among 43 residents over 65. The Maintenance Director provided an inadequate water system schematic, lacking details on water entry and pathogen development areas.
A resident's grievance regarding delayed incontinence care was not properly investigated by the facility. The resident activated the call light, but two GNAs at the nurses' station did not respond, leaving the resident waiting for 26 minutes. The resident's care plan required extensive assistance, and past grievances showed similar issues with delayed responses. The facility's administration confirmed that staff should have alerted a nurse or supervisor and acknowledged a lack of staff education on the resident's care needs.
Facility staff failed to provide necessary care to two residents who relied on staff for assistance with activities of daily living. One resident did not receive scheduled showers, and there was confusion regarding staff assignments, leading to a lack of care documentation. Another resident, requiring extensive assistance with toileting, was left soiled after multiple calls for help. The facility administrator acknowledged the resident was soiled for longer than reasonable.
The facility failed to provide written bed hold notices to two residents or their representatives prior to or within 24 hours of emergency hospital transfers, as required by policy. This deficiency was confirmed through a review of medical records and an interview with the Administrator, revealing a lack of documentation for these notifications.
A facility failed to ensure an LPN had the necessary skills to administer insulin correctly to a resident with type 2 diabetes. The LPN did not prime the insulin pen as per manufacturer's instructions, potentially leading to incorrect dosing. Interviews revealed the LPN's training did not cover insulin pen administration, and the facility's assessment tool indicated a gap in training on medication administration.
A resident over the age of 65 was not offered the pneumococcal vaccination in accordance with CDC guidelines and facility policy. The resident had previously received the PCV13 vaccine but was not administered the subsequent PCV20 until the deficiency was identified. The Infection Preventionist confirmed the oversight during an audit, which had the potential to increase the resident's risk of contracting pneumonia.
Call Light Not Kept Within Reach for Dependent Resident
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident’s call device was kept within reach as required by the resident’s care plan and GNA Kardex. During the initial tour and screening, a resident with a degenerative neurological condition, who was dependent on others for personal care and bed mobility, was observed seated upright in bed, awake, alert, and easily engaged in conversation. The resident reported being unable to reposition themself without assistance and expressed concerns about delays in call bell response times. When the surveyor looked for the call device, it was not visible near the resident, and the resident stated they did not know where it was. The surveyor then observed the call device placed on top of the nightstand located at the foot end of the bed, and the resident stated they could not reach it there and that staff must have left it in that location. The resident’s GNA Kardex included instructions to keep the call light within reach at all times, and documented that the resident was dependent for bed mobility and required set-up assistance for eating. The resident’s care plan also identified a problem of risk for falls due to impaired mobility, weakness, and ambulatory dysfunction, with an intervention specifying that the call light should be within reach when the resident was in bed. Despite these documented requirements, the call device was not placed within the resident’s reach at the time of the surveyor’s observation.
Failure to Timely Report and Failure to Report Allegations of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report, and in one case to report at all, allegations of abuse to the state oversight agency. In the first incident, a facility-reported incident file showed that a resident reported an allegation of abuse to a physical therapy assistant at 10:00 AM on 3/17/25. The initial report to the Office of Health Care Quality (OHCQ) was not sent until 2:13 PM the same day, more than four hours after the allegation was first reported to staff. The Nursing Home Administrator (NHA), who served as the facility’s abuse coordinator, acknowledged that the regulatory reporting clock starts as soon as any staff member is made aware of an allegation and that the facility had a two-hour reporting requirement. The NHA confirmed that the allegation was not reported within the mandated timeframe. During interview, the NHA initially stated that the delay occurred because the physical therapy assistant reported the allegation to the director of rehab, who then reported it to her. However, further review of the investigation packet showed that the assistant had directly reported the allegation to the NHA, contradicting the NHA’s explanation. The NHA also stated that the assistant had been educated to report allegations of abuse immediately. These records and interviews established that the facility did not meet the required timeframe for reporting the allegation of abuse to OHCQ, despite the NHA’s awareness of the reporting standard and her role as abuse coordinator. In the second incident, a grievance form documented that a cognitively intact roommate reported observing a GNA provide abrupt and rough care to a resident with severe cognitive impairment, dementia, and a cognitive communication deficit, who required total assistance with personal hygiene and extensive assistance with turning and repositioning, and was unable to use the call bell. The roommate reported that the GNA entered the room in a poor mood, became frustrated with the resident’s inability to cooperate, grabbed the resident hard, spoke angrily, and used force when laying the resident back down and moving the resident’s legs onto the bed. The roommate reported these concerns to the facility social worker the same morning. The social worker stated that the concern was reviewed by the NHA, who asked the reporting resident if they thought the incident was abuse; when the resident said no, the NHA determined it was not abuse and did not report it to OHCQ. In a subsequent interview, the NHA confirmed that she did not report this allegation because she concluded it did not meet the definition of abuse, despite acknowledging that all allegations of abuse were supposed to be reported.
Failure to Thoroughly Investigate Multiple Abuse Allegations and Document Law Enforcement Notification
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse as required by its own process and regulatory expectations. For Facility Reported Incident (FRI) #351276, involving a resident who alleged that a GNA was rough and hit her while providing care, the investigation file lacked staff witness statements, a statement from the alleged perpetrator, and any resident witness statements or resident assessments. The only resident statement present was an undated questionnaire-style document for Resident #40 that lacked the interviewer’s name and signature. The file also did not contain evidence of the alleged perpetrator’s license, education, or work status, nor copies of both the initial and final reports to the Office of Health Care Quality (OHCQ). When questioned, the NHA and DON stated that the former DON wrote the resident’s statement and that other residents were interviewed and assessed, but they could not provide supporting documentation. For FRI #351281, related to a resident admitted in April and discharged in May who reported that a staff member purposefully struck his left arm and handled him too aggressively, the medical record documented the allegation and a provider assessment noting no obvious signs of trauma. The investigation file contained an unsigned and unnamed statement describing the resident’s report, including that staff slapped the resident’s hand away while handling a urinal and that another staff member was present. The file also included a document signed by the NHA summarizing an interview with Staff #15, indicating the staff member claimed the contact was accidental, and an education acknowledgment signed by Staff #15, as well as a signed statement from Staff #14 who reported being in the room and not hearing a slap. However, there was no signed statement from Staff #15 in the file and no documentation that Staff #15 had been asked to provide a signed statement or had declined or was unavailable, despite corporate guidance that investigative statements should be conducted as interviews with factual data and supported by documentation. For FRI #2623047, the initial report to OHCQ documented that the county sheriff’s office was contacted, but did not identify an officer, report number, or other objective evidence of the contact. The investigation file contained questionnaires reflecting resident and staff interviews but did not identify witnesses to the alleged incident. Within the investigation record, the section for law enforcement notification listed the sheriff’s office but left the date and time of contact blank. A follow-up report stated that a non-communicative resident had a skin assessment with no new areas noted, that residents were interviewed or assessed as applicable, and that the alleged perpetrator (Staff #18) was unaware of the incident due to lack of a specific date/time and was suspended pending investigation. The facility could not provide a signed statement from Staff #18 or documentation of attempts to obtain such a statement, and also could not provide objective documentation (such as date/time, name/badge of the officer, or report number) to verify law enforcement notification as reported to OHCQ.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect four residents from resident-to-resident abuse, as evidenced by multiple incidents involving physical altercations. Resident 22, who was severely cognitively impaired with a diagnosis of Down's syndrome, was involved in two separate incidents. In the first incident, Resident 11, who had a history of aggression and depression, admitted to slapping Resident 22 after being disturbed by noise. In the second incident, Resident 22, who had a history of physical and verbal behaviors, smacked Resident 35, who was severely cognitively impaired, in the dining room. Another incident involved Resident 106, who was cognitively intact but had poor impulse control, pushing past and hitting Resident 11, who then retaliated. These incidents were documented in the facility's investigation reports, and interviews confirmed the occurrences. The facility's policy on abuse, neglect, and exploitation was reviewed, indicating a failure to prevent resident-to-resident abuse. The facility's investigation revealed that there were no witnesses to some of the altercations, and the residents involved had varying levels of cognitive impairment and behavioral issues. The facility's administrator confirmed that these incidents were considered abuse, highlighting a deficiency in ensuring a safe environment for all residents.
Incomplete Water Management Program for Legionella Prevention
Penalty
Summary
The facility's water management program was found to be incomplete and not consistent with current ASHRAE guidelines, which are essential for evaluating the potential exposure to Legionnaire's disease within healthcare facilities. The deficiency was identified through a review of the facility's policy, interviews, and guidelines from the CDC and ASHRAE. The facility's policy, dated December 4, 2022, stated the intention to establish water management plans to reduce the risk of legionellosis and other pathogens. However, the policy lacked a comprehensive risk assessment and control points identification, which are critical components of a water management program. During an interview, the Maintenance Director confirmed that there had been no Legionnaires outbreaks and provided a hand-drawn schematic of the facility's water system, completed on the day of the interview. However, the document failed to include crucial information on how water enters the facility and potential areas for water pathogens to develop. This oversight created a potential risk for the 43 residents, all over the age of 65, to be exposed to Legionella, as the facility did not adequately address the environmental conditions that could promote the growth and transmission of the bacteria.
Failure to Investigate Resident Grievance and Provide Timely Care
Penalty
Summary
The facility failed to investigate a grievance regarding care concerns for a resident, identified as Resident #14. An observation revealed that the resident activated the call light, which was ignored by two geriatric nursing assistants (GNAs) who were present at the nurses' station. An activity assistant (AA) responded to the call light but was unable to provide the necessary incontinence care and informed the GNAs, who did not take further action. The resident waited 26 minutes for care, during which time one of the GNAs was observed using a computer and cell phone. The resident's care plan indicated a need for extensive assistance with incontinence care, contradicting the GNA's claim that the resident had requested not to have her as an aide. A review of past grievances revealed a similar incident where the resident's call light was not promptly answered during breakfast time, and the investigation by the former Director of Nursing (DON) was inadequate. The DON failed to determine the urgency of the resident's needs or the duration of the wait time. Interviews with the current Administrator and DON confirmed that the GNAs should have alerted a nurse or supervisor about the resident's needs instead of making the resident wait. The Administrator acknowledged that the resident had a behavior of requesting care during mealtimes, which was not documented in the care plan, and staff had not been educated on how to handle the resident's specific care needs.
Failure to Provide Adequate Care for Residents
Penalty
Summary
Facility staff failed to provide necessary care to two residents who relied on staff for assistance with activities of daily living. For one resident, there was a failure to assign an aide on a night shift, resulting in care not being provided. The resident's care plan indicated the need for assistance with bathing and personal hygiene, with scheduled shower days on Wednesdays and Fridays. However, documentation revealed that the resident did not receive showers as scheduled, with only two showers documented over an eight-day period. Additionally, there was confusion regarding staff assignments, as a GNA who was supposed to care for the resident did not clock in, and another GNA was not aware of the assignment, leading to a lack of care documentation. Another resident, who required extensive assistance with toileting, reported being left soiled after calling for help multiple times. The resident used the call bell on several occasions, but staff failed to provide timely assistance. The resident was eventually changed by a third GNA, but the facility was unable to determine the exact duration the resident was left soiled. The facility administrator acknowledged that the resident was soiled for longer than reasonable. These incidents highlight a failure in the facility's staffing and care documentation processes, resulting in inadequate care for residents who depend on staff for their daily needs.
Failure to Provide Bed Hold Notices for Hospital Transfers
Penalty
Summary
The facility failed to provide a written bed hold notice to two residents, R23 and R55, or their representatives, prior to or within 24 hours of their emergency transfers to the hospital. This oversight was identified during a review of the facility's policy titled 'Bed Hold Notice Upon Transfer,' which mandates that such a notice be given at the time of transfer. The policy specifies that the notice should include the duration of the bed-hold policy, information on the return of the resident to the next available bed, and documentation of the notice in the medical record. Resident R23 experienced multiple hospitalizations for various medical conditions, including an intertrochanteric fracture, infections, and septic shock, yet there was no documentation of a bed hold notice being provided for any of these transfers. Similarly, Resident R55 was transferred to the hospital due to agitation and aggressiveness, but again, no bed hold notice was documented. An interview with the facility's Administrator confirmed the lack of documentation for these notifications, indicating a systemic failure to comply with the facility's policy.
LPN Lacks Competency in Insulin Pen Administration
Penalty
Summary
The facility failed to ensure that a Licensed Practical Nurse (LPN) possessed the necessary competencies and skills to properly administer insulin to a resident with type 2 diabetes mellitus. During an observation, the LPN did not prime the insulin pen with the required two units to ensure the needle was functioning correctly, instead priming it with only one unit. This action was contrary to the manufacturer's instructions, which could potentially result in the resident receiving an incorrect dose of insulin. The LPN admitted to not recalling any specific training on insulin pen administration during her orientation. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the LPN's competency assessment did not include insulin pen administration. The DON acknowledged that the medication administration observation form needed revision to incorporate insulin pen administration. The facility's documentation confirmed that the LPN was observed administering medications satisfactorily, but insulin pen administration was not part of the evaluation. The facility's assessment tool indicated that staff training should include medication administration, yet this was not adequately addressed in the LPN's training.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer a resident, identified as R37, the opportunity to be vaccinated against pneumococcal disease in accordance with nationally recognized standards. The facility's policy, dated 12/18/22, mandates offering pneumococcal vaccines to residents in line with CDC guidelines. According to the CDC, adults aged 65 years or older should receive pneumococcal vaccination. R37, who was over the age of 65 upon admission, had previously received the PCV13 vaccine on 02/03/16 but had not been offered the subsequent recommended vaccinations until the deficiency was identified. The Infection Preventionist (IP) confirmed during an interview that R37 had received the PCV13 and that the PCV20 was administered only recently, after an audit revealed the oversight. The IP acknowledged that R37 was missed during the recent audit for the PCV20 vaccine, which led to the delay in offering the appropriate vaccination. This oversight had the potential to increase the risk for the resident to contract pneumonia, as the facility did not adhere to its policy and CDC guidelines in a timely manner.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Frederick
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Frederick Crossing Of Journey | 4.2 mi | ★★★★★ | 38 | 0 |
| Citizens Care And Rehabilitation Center Of Frederi | 4.6 mi | ★★★★★ | 16 | 0 |
| Northampton Manor Nursing And Rehabilitation Cente | 6.2 mi | ★★★★★ | 26 | 0 |
| Willowbrooke Ct Skilled Care Buckingham's Choice | 7 mi | ★★★★★ | 11 | 0 |
| Homewood Living Frederick | 7.4 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.