Autumn Lake Healthcare At Silver Spring
AUTUMN LAKE HEALTHCARE AT SILVER SPRING in SILVER SPRING, MD — inspection on April 28, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
authorities.
abuse to the State Agency (SA) within the required timeframe.
This was evident for 1 (#2) of 1
grievance form dated as received on 4/15/26 at 4:30 PM revealed that Resident #2 reported to the facility an allegation of abuse.
The form read that the resident reported on 4/14/26 around 8:30 PM that the assigned geriatric nursing assistant (GNA) came into their room to assist them to go to bed.
When Resident #2 told the GNA s/he was not ready to go to bed, the GNA continued to urge him/her to go to bed and then threatened to slap the resident if they did not go to bed.
The form was signed by Registered Nurse (RN) #7.A review of the facility's investigation file for the facility reported incident #298941 on 4/27/26 at 1:28 PM revealed on the initial report form that the facility was alleging they were not aware of the allegation of abuse until 4/17/26 at 2:30 PM. It was documented that the Ombudsman reported the allegation of abuse to the Nursing Home Administrator (NHA).
The allegation read that Resident #2 alleged that an assigned GNA had hit him/her.
However, on a witness statement form completed by RN #7 and the Assistant Director of Nursing (ADON) revealed that the resident's allegation was the same as the incident s/he reported to the facility on 4/15/26.An interview with the Activity Director #4 on 4/28/26 at 1:18 PM revealed Resident #2 reported the allegation of abuse on 4/15/26 during a resident council meeting.
She stated that the resident informed the group that she was threatened by a staff member who stated she would slap him/her if she did not go to bed.
She stated she left the meeting immediately and verbally reported it to the Nursing Home Administrator (NHA) and the she told the Assistant Director of Nursing (ADON).Surveyor was unable to interview the NHA because she was unavailable during the survey.An interview with the ADON on 4/28/26 at 1:32 PM revealed she was approached by the Activity Director on 4/15/26 about Resident #2's allegation of abuse.
She stated she went to the NHA who told her to write it on a grievance form and start an investigation.
She confirmed she had not reported it to the SA because they were just investigating it at that time.
She stated that the resident alleged it occurred on 4/14/26 in the evening, however, she pointed out GNA #8 who had not been on duty that evening.
When shown the schedule and that GNA #8 had not worked on 4/14/26, but had worked on 4/13/26, she stated she had not noticed that during the investigation.
Furthermore, because the resident reported the wrong date, GNA #8 was allowed to continue to work on 4/15/26 and was assigned to Resident #2.
When asked why the allegation was not reported as an allegation of abuse on 4/15/26, but was reported after the Ombudsman reported it to the NHA, she stated that she was not sure because it was the same allegation that they had already investigated on 4/15/26 and 4/16/26.The concerns were reviewed with Corporate Compliance Officer on 4/28/26 at 2:30 PM.Cross Reference: F-F610 Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
215224 04/28/2026
Autumn Lake Healthcare at Silver Spring 2501 Musgrove Road Silver Spring, MD 20904
safety of all residents until an investigation was completed.
This was evident for 1 (#2) of 1 resident
dated as received on 4/15/26 at 4:30 PM revealed that Resident #2 reported to the facility an allegation of abuse.
The form read that the resident reported on 4/14/26 around 8:30 PM that the assigned geriatric nursing assistant (GNA) came into their room to assist them to go to bed.
When Resident #2 told the GNA s/he was not ready to go to bed, the GNA continued to urge him/her to go to bed and then threatened to slap the resident if they did not go to bed.
The form was signed by Registered Nurse (RN) #7.An interview with the ADON on 4/28/26 at 1:32 PM revealed she was approached by the Activity Director on 4/15/26 about Resident #2's allegation of abuse.
She stated that she and the evening shift supervisor RN #7 worked on an investigation that evening and into the next day (4/16/26).
She reported that they asked the GNA who was assigned to the resident on 4/14/26 during the evening shift to come to the facility on 4/15/26.
When the resident saw her, the resident stated that it was not her and pointed out GNA # 8 and see if that was who the resident was talking about.
The Activity Director stated she went to the NHA who told her to write it on a grievance form and start an investigation.
She confirmed she had not reported it to the SA because they were just investigating it at that time.
She stated that the resident alleged it occurred on 4/14/26 in the evening, however, she pointed out GNA #8.
The ADON reported she had not asked GNA #8 to leave the resident care area because she was not working on the day the resident alleged the incident happened.
She was shown the schedules and that GNA #8 had not worked on 4/14/26, but had worked on 4/13/26, she stated she had not noticed that during the investigation.
She agreed that the resident may not have had the right date but she had clearly identified the GNA #8 who threatened her. An interview with the Ombudsman on 4/28/26 at 11:43 AM revealed she had visited Resident #2 on 4/16/26 around 5:00 PM.
The resident reported the allegation of abuse to her and when GNA #8 came in the room, the resident stated that it was her who had threatened the resident. A review of the facility's investigation file for the facility reported incident #298941 on 4/27/26 at 1:28 PM revealed a witness statement dated 4/17/26, that RN #7 wrote that Resident #2 had pointed out GNA #8 as the alleged perpetrator that day.A review of the time stamps for GNA #8 on 4/28/26 at 1:37 PM revealed she worked the evening shift 4/15/26 - 4/24/26.
Even though the allegation was reported a second time to the NHA on 4/17/26 by the Ombudsman who reported to her that the resident identified GNA #8 as the alleged perpetrator.The surveyor was unable to interview the NHA because she was unavailable during the survey.The concerns were reviewed with Corporate Compliance Officer on 4/28/26 at 2:30 PM.Cross Reference: F-F609
215224 04/28/2026
Autumn Lake Healthcare at Silver Spring 2501 Musgrove Road Silver Spring, MD 20904
During an interview with the Social Services Assistant Staff #6 on 4/27/26 at 11:30 AM, she provided a utilization review sent to the facility by the insurance company.
On that paperwork dated 4/17/26, it noted the resident was eligible for home health and in-home therapy services.
When asked if she had set up those services for the planned discharge on [DATE], she stated that she had notified a home health provider on 4/23/26 around 12 noon.
However, the evidence she provided showed she had not sent a request until 4/23/26 at 3:26 PM which was during the discharge meeting with the resident.
She reported she was unaware she could set up the services prior to the discharge date .
She reported that the resident was not discharged because they were unable to find a home health provider that accepted the resident's insurance although there was a list of providers on the utilization review paperwork she presented during the interview.An interview with the Ombudsman on 4/28/26 at 11:46 AM revealed that Resident #1's family member called her on 4/24/26 and put her on speaker during a discharge meeting.
She stated that until she asked for social services to be present, they had not been at the meeting.
She confirmed that the facility had not secured home health and therapy services for Resident #1's discharge home.
She stated she informed them that the home health provider they were trying to secure was not listed on the utilization review dated 4/17/26.The Nursing Home Administrator (NHA) was not available during the survey.
The concerns were reviewed with the Corporate Compliance Officer on 4/28/26 at 2:30 PM and she acknowledged the concerns.
215224 04/28/2026
Autumn Lake Healthcare at Silver Spring 2501 Musgrove Road Silver Spring, MD 20904
According to section GG, the resident required staff assistance with most ADLs (activities of daily living such as toileting, dressing, bathing, personal hygiene) and was wheelchair bound.A note dated 4/14/26 from the Social Services Director Staff #2 stated the resident's insurance coverage was ending and the resident agreed to go home on 4/15/26.
Then later that day Staff #2 wrote that the resident wanted to appeal the decision. On 4/16/26, the resident was visited by Nurse Practitioner (NP) #1 and she wrote the resident was admitted for generalized muscle weakness.
The resident had mobility and ADL dysfunction and was at risk for functional impairment without pain control and physical and occupation therapy services.
The attending physician wrote a note on 4/16/26, stating the resident was in extensive need of therapy and was not ready to be discharged to his/her home. A review of therapy notes for the resident revealed s/he had not had therapy since 4/16/26.An interview with Resident #1 on 4/23/26 at 12:08 PM revealed s/he was scheduled to go home that day.
The resident reported s/he had concerns about going home because they felt they needed more therapy to be safe at home and had appealed the insurance decision to send them home.
The resident reported that they were granted an extended stay, but had not received any more therapy since 4/16/26.The Social Services Director Staff #5 was interviewed on 4/27/26 at 10:22 AM and confirmed that the resident was supposed to discharge on [DATE], but had been granted additional days and then the resident appealed that decision and was granted to stay until 4/22/26.
Physical Therapist (PT) #9 was interviewed on 4/27/26 at 12:00 PM and she reported that Resident #1 had participated in therapy but had not reached his/her goals.
She stated that the resident needed to improve his/her navigation of steps before going home. PT #9 reported that even though the resident had been approved for services until 4/23/26 sometimes the insurance would stop the services. An interview with the Rehab Director #10 on 4/27/26 at 12:12 PM confirmed that Resident #1 had not had services since 4/16/26 and that she was aware the resident had been appealing the insurance decision to discharge.
She stated that when the resident was extended it was for custodial reasons based on abnormal labs which was why she had not extended the resident's therapy services.
However, she wanted to look at some paperwork and get back to the surveyor. On 4/27/26 at 12:40 PM Rehab Director #10 came back and reported Resident #1 had met his/her therapy goals for skilled nursing services and so the insurance company felt the resident could continue therapy services at home.
When asked why they had not continued to provide therapy through the appeal processes she stated it was back and forth with this resident and she was not sure what was going on with the discharge.
She reported that the resident would experience a physical decline without therapy services for 11 days and that they were going to start services again until the resident was discharged .
The surveyor was unable to interview the Nursing Home Administrator because she was unavailable.
The concerns were reviewed with the Corporate Compliance Officer on 4/28/26 at 2:30 PM and she acknowledged the concerns.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.