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 Waugh Chapel during CMS and state inspections, most recent first.
Failure to follow a physician order to hold an antihypertensive medication when a resident’s SBP was below 110 mm/Hg. A resident with HTN, post vascular surgery, and arthritis received Amlodipine on multiple occasions despite BP readings below the ordered threshold, and an RN later acknowledged the doses should have been withheld.
The facility failed to ensure food safety in two nourishment room refrigerators, risking foodborne illness. A surveyor found spoiled food items dated beyond the safe storage period, which were validated and removed by staff. An LPN confirmed that food from outside should not be stored for more than three days. The Infection Preventionist acknowledged the issue.
A resident with a Foley catheter was transported to and from rehabilitation activities without their urinary drainage bag being covered, compromising their dignity. The COTA responsible for the transport acknowledged the oversight, stating that nurses were responsible for applying dignity bags. The acting DON confirmed that the facility provides leaf bags for this purpose and that residents should not be transported without them.
A resident reported being slapped on the hand by a GNA during care, which was substantiated by the facility's investigation. The resident was cognitively intact, and the incident occurred when they reached towards their Foley catheter. The GNA's account was found to be conflicting, leading to their termination after the abuse allegation was confirmed.
A facility failed to report an abuse allegation within the required 2-hour timeframe to the Office of Health Care Quality (OHCQ). A resident reported being hit by a GNA after admitting to punching the GNA. The DON and NHA were informed of the incident, but the report was submitted over 3 hours later. The NHA confirmed the facility's procedure requires reporting within two hours, and the DON admitted to the late submission.
A facility failed to develop a comprehensive care plan for a resident with frequent UTIs, despite multiple antibiotic treatments. The care plan did not include strategies for managing and preventing UTIs. Interviews with staff confirmed regular care plan meetings, but the resident's plan lacked specific measures for UTI prevention.
The facility failed to update care plans for two residents, leading to deficiencies in care. One resident with hemiplegia was observed without a required bolster, and another resident's care plan lacked non-pharmacological interventions for pain management. Both care plans had not been revised since August, despite new medical orders.
A resident with hemiplegia and hemiparesis had a prescribed order for a soft bolster to manage a left arm contracture, but the facility failed to consistently use it. Instead, staff sometimes used a folded pillow, and the bolster was found unused in the resident's closet. This failure to adhere to the care plan resulted in a deficiency in providing resident-centered care.
A facility failed to provide appropriate pain management for a resident by not offering nonpharmacological interventions before administering pain medications like Acetaminophen and Oxycodone. Medical records and staff interviews confirmed that these interventions were not attempted, despite being required by physician's orders. This deficiency was identified during a survey.
Failure to Hold Antihypertensive Medication for Low Blood Pressure
Penalty
Summary
Nursing staff failed to follow a physician order to hold Amlodipine Besylate 2.5 mg when the resident’s systolic blood pressure was less than 110 mm/Hg. The resident was admitted with diagnoses including post vascular surgery, arthritis, and hypertension and required assistance from nursing staff for some aspects of care. The closed medical record showed an order dated 08/09/25 directing the medication to be given once daily and held for systolic blood pressure readings below 110 mm/Hg. Review of the August and September 2025 MARs showed the medication was administered at 9 AM on multiple occasions when the resident’s blood pressure was below that threshold, including readings of 109/74, 106/70, 109/70, and 100/60. During interview, Staff Nurse #1 stated the doses should have been withheld on those dates because the blood pressure readings were less than 110 mm/Hg.
Food Safety Deficiency in Nourishment Room Refrigerators
Penalty
Summary
The facility failed to maintain the safety of food items in two nourishment room refrigerators, which could potentially lead to foodborne illness. During a surveyor's tour, a large zip-lock bag with cooked food items and an uncooked cauliflower, both dated 03/08/25, were found in a refrigerator near the 400-unit Nurses' station. The cauliflower was brown to black in color, indicating spoilage. An LPN validated these findings and removed the items. Additionally, apple sauce dated 03/08/25 was found in another refrigerator near the 200-unit Nurses' station, which was also validated and removed by a unit secretary. An interview with the LPN revealed that food brought from outside the facility for residents should be dated and stored for no more than three days, indicating that the items found were past their safe storage period. The Infection Preventionist reviewed and validated these concerns.
Failure to Maintain Resident Dignity During Transport
Penalty
Summary
The facility failed to maintain a resident's dignity by not covering the urinary drainage bag during transport to and from rehabilitation activities. This deficiency was identified during a recertification/complaint survey for a resident with a Foley catheter. On the initial tour, the resident was observed with a urinary drainage bag partially filled with urine hanging under the bed. Later, the resident was seen being wheeled back to their room in a wheelchair by a Certified Occupational Therapy Assistant (COTA), with the urinary bag uncovered. In an interview, the COTA acknowledged that the urinary bag should have been covered with a dignity bag during transport and stated that it was the nurses' responsibility to apply the dignity bag. The acting Director of Nursing (DON) confirmed that the facility provides leaf bags to conceal urinary drainage bags during transport and that residents should not be transported without them. The DON was made aware of the concern and indicated she would investigate the issue.
Resident Abuse Incident Involving GNA
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a geriatric nursing assistant (GNA) and a resident. The resident, who was cognitively intact with a BIMS score of 13 out of 15, reported that the GNA slapped the back of their hand during care. This incident occurred when the resident reached towards their Foley catheter while asking a question. The facility's investigation included statements from the resident, the GNA, and other staff members. The resident's account was deemed credible, while the GNA's account contained conflicting information. The Director of Nursing confirmed that the allegation of abuse was substantiated, leading to the termination of the GNA. The Human Resource Director explained the facility's process for handling abuse allegations, which includes suspending the staff member during the investigation and terminating employment if the allegation is substantiated. The investigation concluded that the GNA's actions constituted a violation, resulting in the resident's perception of abuse.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility staff failed to report an allegation of abuse within the required 2-hour timeframe to the regulatory agency, the Office of Health Care Quality (OHCQ). This deficiency was identified during a recertification/complaint survey for a resident who reported being hit by a Geriatric Nursing Assistant (GNA) after the resident admitted to punching the GNA. The Director of Nursing (DON) was informed of the allegation at 3:00 PM, and the Nursing Home Administrator (NHA) was informed at 4:50 PM on the same day. However, the initial self-report of the allegation was not submitted to the State Survey Agency until 6:13 PM, which was more than 3 hours after the facility staff were made aware of the incident. During interviews, the NHA confirmed that the facility's procedure requires any allegation of abuse to be reported within two hours, regardless of substantiation. The discrepancy in reporting times was verified through documentation and email confirmation receipts, which showed the report was submitted later than the required timeframe. The DON admitted to submitting the report late, explaining that she had to rush home to do so, acknowledging the facility's failure to comply with the 2-hour reporting requirement.
Failure to Develop Comprehensive Care Plan for Frequent UTIs
Penalty
Summary
The facility failed to initiate and develop a comprehensive person-centered care plan for a resident who had frequent urinary tract infections (UTIs). The medical record review revealed that the resident had multiple UTIs and was treated with antibiotics on several occasions, including Keflex, Cipro, and Bactrim. Despite these recurring infections, the care plan did not address the risks and prevention strategies for UTIs. Interviews with facility staff, including Social Services and the Infection Preventionist, confirmed that care plans are conducted regularly, with individual departments responsible for initiating and revising them. However, it was validated that the resident's care plan lacked specific measures for managing and preventing frequent UTIs, indicating a deficiency in the facility's care planning process.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to review and revise the comprehensive care plans for two residents, leading to deficiencies in their care. Resident #13, who was admitted with a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, was observed without a required bolster for left arm contracture. Despite having a medical order for the bolster, the care plan did not include this intervention, and the last revision of the care plan was dated 08/21/23. This oversight was confirmed by the unit manager and the Infection Preventionist. Similarly, Resident #35, who was receiving long-term care, had a medical order for non-pharmacological interventions to be attempted before administering PRN pain medication. However, the care plan, last revised on 08/21/23, did not reflect these interventions. This deficiency was also validated by the Infection Preventionist. Both cases highlight the facility's failure to ensure that care plans were accurately updated to reflect current medical orders and interventions.
Failure to Use Prescribed Bolster for Resident's Contracture
Penalty
Summary
The facility failed to provide resident-centered care in accordance with the resident's goals and professional standards of practice, as evidenced by the case of a resident with hemiplegia and hemiparesis following a cerebral infarction. The resident, who was admitted for long-term care, had a documented order for a soft bolster to be used for left arm positioning related to contracture. This order specified the placement of the bolster to ensure proper positioning and airflow. However, during the survey, it was observed that the resident's left arm contracture was not being treated with the prescribed bolster or any similar device. Interviews with facility staff revealed that the bolster was not consistently used as ordered. An LPN admitted to not seeing the bolster in use during medication administration and mentioned that a folded pillow was sometimes used instead. The unit manager confirmed the existence of the bolster order but acknowledged the use of a folded pillow. Additionally, the Infection Preventionist verified that the bolster was found in the resident's closet, indicating it was not in use as required. This lack of adherence to the prescribed care plan resulted in a deficiency in meeting the resident's physical needs.
Failure to Provide Nonpharmacological Interventions Before Pain Medication
Penalty
Summary
The facility failed to provide appropriate pain management for Resident #35, as evidenced by the lack of nonpharmacological interventions prior to administering pain medication. The medical record review revealed that pain medications, including Acetaminophen and Oxycodone, were administered to the resident without any documented attempts to offer nonpharmacological interventions, such as repositioning or offering a warm beverage, as required by the physician's orders. This deficiency was identified during the recertification/complaint survey. Interviews with the staff, including Licensed Practical Nurses (LPNs), confirmed that pain medications were given after assessing the resident's pain but without ensuring that nonpharmacological methods were attempted first. The Infection Preventionist also validated that the PRN medications were administered without offering these interventions. This oversight in pain management practices was evident for Resident #35, who was one of the two residents reviewed for pain management during the survey.
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What surveyors actually found near you
We read the 1,996 citations issued within 25 miles in the last 12 months — including the 12 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Gambrills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Autumn Lake Healthcare At Crofton | 2.1 mi | ★★★★★ | 24 | 0 |
| Fairfield Nursing & Rehabilitation Center | 4.1 mi | ★★★★★ | 48 | 0 |
| Complete Care At Severna Park Llc | 6.5 mi | ★★★★★ | 6 | 0 |
| Future Care Annapolis | 6.9 mi | — | 0 | 0 |
| Larkin Chase Center | 7.3 mi | ★★★★★ | 9 | 2 |
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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.