Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Oakview during CMS and state inspections, most recent first.
The facility inaccurately coded MDS assessments for multiple residents. One resident discharged home AMA was coded as discharged to a short-term general hospital, another resident with active orders and psych notes for bipolar disorder and depression was not coded for depression, and two residents were incorrectly coded as receiving anticoagulants despite no orders or MAR evidence of anticoagulant use. The MDS coordinator acknowledged the coding errors.
Refrigerator temperatures in the 3rd floor nourishment room were not maintained at a safe level, and the recorded log did not match surveyor observations. The thermostat read 52 F, 50 F, and 54 F on separate observations, while staff documentation repeatedly listed 38 F. GNA and RN staff identified the refrigerator as the storage location for resident food brought from outside the facility, and the RN stated the thermostat was used for temperature documentation.
A resident questioned a $1000 deduction from their personal funds account and was unable to obtain a receipt or documentation for the transaction from the facility. The business office could not locate any record of the transaction and did not provide a written response to the resident's concern.
Three substantiated incidents occurred in which a resident physically assaulted two other residents, resulting in injuries and ER visits, and a nurse was witnessed by a family member slapping a resident with dementia. Facility investigations confirmed the abuse through staff and witness interviews, as well as medical record review.
A resident questioned a $1000 deduction from their personal funds account, and the facility was unable to provide a receipt or documentation for the transaction. Despite the resident filing a grievance and the business office manager notifying the NHA, no explanation or records were given, and the incident was not reported to authorities. The facility failed to protect the resident from misappropriation of property.
Surveyors found that the facility did not report incidents of injury of unknown origin, resident-to-resident abuse, and suspected misappropriation of resident funds to the state agency within required timeframes. In each case, staff or administration were aware of the incidents but failed to notify authorities promptly, as confirmed by documentation and interviews.
A resident's right to choice was not honored when staff gave bed baths instead of the resident's scheduled showers. The resident stated they wanted showers, but the record showed repeated bed baths on shower days with no documentation of refusal. An LPN said the resident preferred bed baths to get into a power chair quickly, but that preference was not documented.
A resident questioned a $1,000 deduction from personal funds and provided a statement showing the charge as Personal Needs Items, but the facility could not produce a receipt or explain the transaction. The grievance was investigated by the Business Office Manager, who found no supporting record, and no response or resolution was provided to the resident. The NHA said the issue was being worked on with corporate finance, but the alleged misappropriation was not reported to the proper authorities.
A resident with dementia was incorrectly scored as low risk on an elopement assessment because the LPN missed the dementia diagnosis and marked mobility incorrectly. Based on that inaccurate assessment and a care plan listing the resident as not an elopement risk, the resident was allowed to sign out and was later found outside in the parking lot after walking away from the facility. The receptionist said the resident was not on the elopement risk list, and the DON confirmed the diagnosis and ambulatory status should have been marked differently.
Failure to properly assess and monitor a wander guard for a resident at high risk for elopement. The resident had a hx of multiple elopement attempts and was ordered to have wander guard placement checked every shift. Staff documented the device as being in place without actually checking it, and the resident was later observed without the wander guard on while stating they were desperate to leave and had removed it days earlier because they felt like they were being tracked.
Failure to honor a resident’s food preferences and lactose intolerance. A resident reported repeated service of Lactaid milk and oatmeal despite telling the dietary manager they disliked both items and that they caused diarrhea episodes; the resident requested cream of wheat instead. The resident’s record confirmed lactose intolerance, and staff confirmed the resident was served the disliked breakfast items.
Unsafe and unsanitary conditions were observed in a resident’s room, including a strong musty or moldy odor and black substances under the bathroom sink and on the bathroom floor. The Unit Mgr acknowledged the odor and stated she had become aware of the mold problem the prior week; she also reported the DON was not aware of the concern at that time.
Loose hallway handrails were observed on the 2nd floor nursing unit, including a handrail across from the elevator and another to the right when exiting the elevator. The metal brackets were pulled away from the wall with drywall attached, and the Maintenance Director stated that staff had been told to check handrails periodically, but there was no documentation of those checks.
Inaccurate MDS Coding for Discharge Location, Diagnoses, and Medication Use
Penalty
Summary
The facility failed to accurately code resident status in the MDS for 4 of 8 residents reviewed for assessment accuracy. For one resident, progress notes documented discharge home Against Medical Advice, but the discharge MDS coded the discharge location as a short-term general hospital instead of home. The MDS coordinator stated she used nursing notes, social services notes, and census information to determine discharge location and acknowledged the discharge location should have been coded as home. For another resident, the medical record showed active orders and MAR documentation for Aripiprazole for bipolar disorder and Fluoxetine hydrochloride for depression, and psychiatric notes indicated ongoing treatment for both conditions, but the MDS completed on 7/6/25 did not reflect an active diagnosis of depression disorder. For two additional residents, the MDS coded anticoagulant use in Section N0421 even though the residents had no anticoagulant orders and their MARs showed they were not receiving anticoagulant medications during the relevant review periods. The MDS coordinator stated she reviewed the MAR to determine coding and confirmed the anticoagulant entries were coded incorrectly.
Refrigerator temperatures were inaccurately documented
Penalty
Summary
The facility failed to maintain refrigerated food temperatures at a safe level in the 3rd floor nourishment room refrigerator during the annual survey. Surveyors observed the refrigerator thermostat reading 52 F on 7/24/2025, 50 F on 7/25/2025, and 54 F on 7/28/2025, while the temperature logbook on top of the refrigerator documented 38 F on each of those days. The refrigerator had a sign on the outside stating it was reserved for residents only. The survey team reviewed the logbook and found signed staff documentation that did not match the actual temperatures observed inside the refrigerator. GNA #11 stated that outside food is dated, labeled, and placed in the refrigerator for residents. RN #12 identified the same refrigerator as the storage location for resident food brought from outside the facility and stated that the thermostat inside the refrigerator is used for documenting temperatures. RN #12 said they were not aware of the temperature discrepancies and that the night shift nurse was responsible for documenting the daily refrigerator temperature.
Failure to Provide Receipt and Maintain Records for Resident Personal Funds
Penalty
Summary
The facility failed to maintain proper bookkeeping techniques for a resident's personal funds. A resident questioned a $1000 deduction from their account labeled as Personal Needs Items and requested a receipt for the transaction. The facility was unable to provide the resident with a receipt or retain a copy of it. The resident had previously discussed the issue with both the business office and the corporate financial group, but no documentation supporting the transaction was found in the business office records. The business office manager confirmed that a grievance regarding the missing receipt was received from the resident and investigated, but no record or receipt for the $1000 transaction could be located. The business office manager reported the issue to the Nursing Home Administrator, and documentation of the grievance and notification was provided to the survey team. However, the resident was not provided with a written response to their concern.
Failure to Prevent Resident and Staff Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by three substantiated incidents involving both resident-to-resident and staff-to-resident abuse. In two separate events, one resident physically assaulted two other residents on different occasions, resulting in both victims sustaining injuries that required emergency room evaluation. Witnesses, including LPNs and GNAs, confirmed that the assaults were unprovoked and led to falls and physical harm. The facility's investigations substantiated these incidents through staff interviews and medical record reviews. In a separate incident, a nurse was observed by a family member slapping a resident with dementia on a locked unit. The family member, who had a history of visiting the facility, reported the abuse to staff, and the nurse was subsequently asked to leave and terminated after the allegation was substantiated. The resident involved in this incident no longer resided at the facility. The Director of Nursing confirmed the findings of the investigation and the credibility of the witness.
Failure to Protect Resident from Misappropriation of Funds
Penalty
Summary
A resident reported a $1000 deduction from their personal funds account, labeled as 'Personal Needs Items,' for which the facility was unable to provide a receipt or documentation. The resident had previously raised the concern with both the business office and the corporate financial group, but no explanation or supporting records for the transaction were given. The issue was formally submitted as a grievance to the social services department, which was then investigated by the business office manager. Despite searching, no receipt or record of the transaction was found in the business office records. The business office manager notified the Nursing Home Administrator (NHA) of the missing funds and lack of documentation. However, the facility did not provide the resident with a response or resolution to their concern. Additionally, the NHA did not report the alleged misappropriation of funds to the appropriate authorities after being notified. The resident's request for clarification and documentation regarding the $1000 charge remained unresolved, and the facility failed to protect the resident from misappropriation of property as required.
Failure to Timely Report Suspected Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to report incidents of suspected abuse, neglect, or misappropriation of resident property to the state agency within the required timeframes. In one case, a resident with dementia was found with discoloration around the left eye during morning care, and the injury of unknown origin was not reported to the state agency until later the same day, after the DON and NHA were notified. In another incident, a resident was struck by another resident, resulting in a fall and head injury; this alleged resident-to-resident abuse was not reported to the state agency within the mandated 2-hour window after the NHA was made aware of the event. Additionally, a complaint regarding a $1000 deduction from a resident's funds was not reported to the proper authorities after the concern was brought to the attention of the NHA. The business office manager investigated the missing funds and, upon failing to find a record of the transaction, notified the NHA, who acknowledged awareness of the issue but did not report the alleged misappropriation to the state agency. These failures were identified through record review and staff interviews, and were found to be part of an ongoing issue with timely reporting of such incidents.
Failure to Honor Resident Shower Preference
Penalty
Summary
The facility failed to honor a resident's right to self-determination and choice by not providing the resident's requested shower preference. Resident #11 was interviewed by surveyors and stated they had not received a shower during the week and wanted to receive showers. The resident's record showed an order for bi-weekly showers on Mondays and Thursdays during day shift, but the documentation for May 2025, June 2025, and July 2025 showed bed baths on the scheduled shower days instead of showers. Further review of the record showed no documentation that Resident #11 refused showers. When interviewed, the resident again stated they had not received the scheduled shower for the day and said they would like a shower. An LPN stated the resident wanted to get into their power chair quickly in the morning and preferred bed baths, but this preference was not documented in the record. The DON stated she would educate staff about honoring the resident's preferences.
Failure to Record and Resolve Grievance About Resident Funds
Penalty
Summary
The facility failed to record and make prompt efforts to resolve a grievance involving a resident’s personal funds. Resident #44 questioned a $1,000 deduction from their account dated 9/22/2022 and stated they had asked the Business Office and corporate financial group for an explanation. The resident provided a quarterly statement showing the $1,000 deduction labeled as Personal Needs Items and stated the facility could not provide a receipt for the transaction when requested. A grievance from Resident #44 was dated 3/28/2025 and was later emailed to the Nursing Home Administrator on 4/4/2025 after the Business Office Manager investigated and could not find a receipt or record of the transaction in the business office records. The Business Office Manager stated no response or resolution had been provided to the resident. During interview, the NHA stated they were aware of the concern and had been trying to resolve it with corporate finance, but also stated they did not report the alleged misappropriation of the resident’s funds to the proper authorities on 4/4/2025.
Resident with dementia left unsupervised after inaccurate elopement assessment
Penalty
Summary
The facility failed to prevent a resident with cognitive impairment from leaving the facility unsupervised. Resident #143 had a documented diagnosis of dementia in hospital records and was admitted/readmitted with an elopement screening completed on 2/5/24. That assessment incorrectly failed to identify the dementia diagnosis and incorrectly marked the resident as ambulatory, resulting in a score of 2 points and classification as low risk for elopement, when the score should have been 9 points and the resident should have been considered at risk under the facility policy. The baseline care plan also listed the resident as not an elopement risk, and the resident was not reassessed again until 4/5/24. On 4/5/24, the resident was found outside in the parking lot after signing out at the front desk. A receptionist stated the resident wanted to go outside and was allowed to sign out because the resident was not on the elopement risk list. The resident was reported to have gone up the hill and was about 100 feet from the property line before an employee drove up behind the resident and the resident was brought back inside by the UM. The facility investigation noted the resident was then reassessed and determined to be an elopement risk, and a wander guard bracelet was placed on the resident. During interview, the LPN who completed the original assessment stated she missed the dementia diagnosis and marked mobility incorrectly, and the DON confirmed the dementia diagnosis and ambulatory status should have been marked appropriately.
Failure to Properly Monitor Wander Guard Placement
Penalty
Summary
Facility staff failed to properly assess and monitor a resident's wander guard for a resident who was identified as high risk for elopement. The resident scored as high risk for elopement on 6/17/25, with documentation noting multiple attempts to elope. On 7/17/25, an order was entered to check wander guard placement every shift daily. During observations on 7/24/2025, the resident approached the surveyor and stated they wanted to go home and that the place felt like a prison. On 7/30/2025, the resident was observed walking around the first floor and stated they were desperate to leave the facility. The resident did not have a wander guard on the right ankle. A brief record review showed staff had documented wander guard placement on 7/29/25 for the morning, afternoon, and night shifts. During interview, Staff #7 acknowledged documenting that the wander guard was on the resident's right ankle without checking for placement. Staff #23 confirmed the resident did not have a wander guard on, and the resident stated they had thrown the wander guard in the toilet 4 days earlier because they felt like they were being tracked. The Facility Administrator stated the resident was at very high risk for elopement and was aware of the resident's request to leave the facility.
Failure to Honor Resident Food Preferences and Lactose Intolerance
Penalty
Summary
The facility failed to accommodate a resident’s food preferences and lactose intolerance by continuing to serve Lactaid milk and oatmeal despite the resident’s repeated reports that both items were disliked and caused diarrhea episodes. During the resident council meeting, the resident stated that staff had been informed several times, including the dietary manager, that they wanted cream of wheat instead of oatmeal. The resident’s medical record confirmed lactose intolerance. Staff confirmed that the resident received Lactaid milk and oatmeal on the breakfast tray, and the dietary manager acknowledged discussing the resident’s dislike of those items the prior week but was unsure why the resident was still served them.
Unsafe and Unsanitary Resident Room Conditions
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for Resident #126, as evidenced by repeated observations of a strong musty or moldy odor in the resident’s room and bathroom. On 7/24/2025, a surveyor observed a strong musty smell and black substance underneath the resident’s bathroom sink. On 8/01/2025, two surveyors again observed a strong moldy smell upon opening the room door, and the second-floor Unit Manager entered the room and acknowledged the odor. The bathroom floor was noted to have black substances. During interview, the Unit Manager stated she had become aware of the mold problem in the resident’s bathroom the prior week and reported that Resident #126 sometimes does not allow staff to enter or remain in the room for long periods. She also stated the DON was not aware of the mold concern at that time.
Loose Hallway Handrails
Penalty
Summary
The facility failed to have a process in place to ensure that handrails were securely attached to the wall, as evidenced by a loose handrail on the 2nd floor nursing unit directly across the hallway from the elevator doors. During observation, the metal bracket securing the handrail to the wall was pulled away with drywall attached, and the handrail to the right when stepping out of the elevator was also loose with the bracket pulled away from the wall. During a later observation with the Maintenance Director and the NHA, both acknowledged the concern. The Maintenance Director stated that maintenance workers had been instructed to check the handrails periodically, but there was no documentation of this task.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,422 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Silver Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Turtle Creek Rehabilitation And Wellness Center | 0.8 mi | ★★★★★ | 9 | 1 |
| Regency Care Of Silver Spring, Llc | 1.4 mi | ★★★★★ | 7 | 0 |
| Autumn Lake Healthcare At Chevy Chase | 1.7 mi | ★★★★★ | 5 | 0 |
| Autumn Lake Healthcare At Arcola | 1.9 mi | ★★★★★ | 23 | 0 |
| Fox Chase Healthcare | 2 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.