Inspection > 2 years ago

Overview

Address
35 MILKSHAKE LANE, ANNAPOLIS, MD 21403
Phone
4102695100
Certified beds
130
Avg daily residents
114 (88% of beds filled)
Ownership
For-profit LLC
Provider type
Medicare and Medicaid
Medicare/Medicaid since
1994-01-06
Setting
Urban
2 /5
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
2/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
2/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
5/5
Quality Measures breakdown
Long-Stay Quality Measures 5/5
Short-Stay Quality Measures 5/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
3.78 4.39 3.33 ≥ 3.48
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
0.53 0.77 0.46 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
1.43 0.97 1.26
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
1.83 2.65 1.61
Licensed (RN + LPN)
Combined licensed nurse coverage.
1.96
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
0.15

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
3.42
hrs / resident / day
RN (weekend)
0.39
hrs / resident / day
Total nurse (adjusted, weekend)
3.00
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
54.9%
annual
RN turnover
54.5%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.56
higher acuity than avg
Case-Mix Index Ratio
1.13
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2023-02-03 35 22 13 188 1 188
Cycle 2/3 (prior) 2018-11-05 21 21 0 221 1 221
Total weighted health score
196.3
lower is better

Deficiencies (62)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

61 D/E/F Actual harm — potential for minor
1 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0658 Ensure services provided by the nursing facility meet professional standards of quality. E 2025-08-06 2025-10-04
0908 Keep all essential equipment working safely. F 2025-08-06 2025-10-04
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. D 2025-06-04 2025-07-10
0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. E 2025-06-04 2025-07-10
0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. D 2025-06-04 2025-07-10
0641 Ensure each resident receives an accurate assessment. E 2025-06-04 2025-07-10
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2025-06-04 2025-07-10
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2025-06-04 2025-07-10
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2025-06-04 2025-07-10
0840 Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. D 2025-06-04 2025-07-10
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2025-06-04 2025-07-10
0880 Provide and implement an infection prevention and control program. E 2025-06-04 2025-07-10
0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. E 2025-06-04 2025-07-10
0550 Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. E 2023-02-03 2023-04-05
0558 Reasonably accommodate the needs and preferences of each resident. E 2023-02-03 2023-04-05
0559 Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. D 2023-02-03 2023-04-05
0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. D 2023-02-03 2023-04-05
0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. D 2023-02-03 2023-04-05
0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). D 2023-02-03 2023-04-05
0610 Respond appropriately to all alleged violations. D 2023-02-03 2023-04-05
0636 Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. E 2023-02-03 2023-04-05
0638 Assure that each resident’s assessment is updated at least once every 3 months. D 2023-02-03 2023-04-05
0641 Ensure each resident receives an accurate assessment. E 2023-02-03 2023-04-05
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2023-02-03 2023-04-05
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2023-02-03 2023-04-05
0679 Provide activities to meet all resident's needs. D 2023-02-03 2023-04-05
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. D 2023-02-03 2023-04-05
0692 Provide enough food/fluids to maintain a resident's health. D 2023-02-03 2023-04-05
0732 Post nurse staffing information every day. D 2023-02-03 2023-04-05
0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. D 2023-02-03 2023-04-05
0761 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. D 2023-02-03 2023-04-05
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. D 2023-02-03 2023-04-05
0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently. D 2023-02-03 2023-04-05
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2023-02-03 2023-04-05
0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. D 2023-02-03 2023-04-05
0565 Honor the resident's right to organize and participate in resident/family groups in the facility. D 2018-11-05 2018-12-29
0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. D 2018-11-05 2018-12-29
0623 Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. D 2018-11-05 2018-12-29
0625 Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. D 2018-11-05 2018-12-29
0641 Ensure each resident receives an accurate assessment. D 2018-11-05 2018-12-29
0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted D 2018-11-05 2018-12-29
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2018-11-05 2018-12-29
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2018-11-05 2018-12-29
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. E 2018-11-05 2018-12-29
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2018-11-05 2018-12-29
0692 Provide enough food/fluids to maintain a resident's health. E 2018-11-05 2018-12-29
0730 Observe each nurse aide's job performance and give regular training. D 2018-11-05 2018-12-29
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2018-11-05 2018-12-29
0756 Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. D 2018-11-05 2018-12-29
0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. D 2018-11-05 2018-12-29

Showing 50 most recent of 62. See the All Data CSV for the full list.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 30.1% Medicaid 56.6% Other 13.2%

Operating performance

Operating Margin
1.6%
Total Margin
2.5%
Occupancy Rate
88.3%
Cost per Resident Day
$68

Revenue & costs

Net Patient Revenue
$20.1M
Total Costs
$2.8M
Net Income
$507K

Balance sheet

Total Assets
$5.4M
Total Liabilities
$1.4M
Fund Balance
$4.0M
Current Ratio
4.32

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: AUTUMN LAKE HEALTHCARE

Chain ID
56
Facilities in chain
60
Legal business name
35 MILKSHAKE OPCO LLC
Chain-average star ratings (for peer context)
Overall
2.8
Health
2.6
Staffing
2.5
QM
3.9

Owner / manager organizations (3)

Organization Role Association
35 MILKSHAKE HOLDCO LLC 5% OR GREATER DIRECT OWNERSHIP INTEREST since 05/01/2021
A&R STERN FAMILY MD1 HOLDINGS LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 05/01/2021
HATZLACHA RABBAH LLC 5% OR GREATER INDIRECT OWNERSHIP INTEREST since 05/01/2021

Owner / manager individuals (3)

Name Role Association
MCINERNEY, ELLEN OPERATIONAL/MANAGERIAL CONTROL since 08/01/2022
NEEL, ELIZABETH OPERATIONAL/MANAGERIAL CONTROL since 07/27/2021
SCHWARTZ, MARK OPERATIONAL/MANAGERIAL CONTROL since 05/01/2021

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
No
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

Download CSV

Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $68 metrics.cost_per_resident_day
Cost Report Current Ratio 4.32 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 56.6% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 30.1% metrics.medicare_day_share
Cost Report Net Income ($) $506,650 metrics.net_income
Cost Report Net Patient Revenue ($) $20,060,594 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 88.3% metrics.occupancy_rate
Cost Report Operating Margin (%) 1.6% metrics.operating_margin
Cost Report Total Assets ($) $5,387,931 metrics.total_assets
Cost Report Total Costs ($) $2,830,620 metrics.total_costs
Cost Report Total Fund Balances ($) $3,955,817 metrics.fund_balance
Cost Report Total Liabilities ($) $1,432,114 metrics.total_liabilities
Cost Report Total Margin (%) 2.5% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 1.25927 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 1.60642 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.46222 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.32790 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 3.00358 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 114.2 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.97433 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.64801 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.76799 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 4.39033 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 3.86961 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.6 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.8 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 3.9 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.5 Chain Average Staffing Rating
Provider Information Chain ID 56 Chain ID
Provider Information Chain Name AUTUMN LAKE HEALTHCARE Chain Name
Provider Information City/Town ANNAPOLIS City/Town
Provider Information CMS Certification Number (CCN) 215258 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community N Continuing Care Retirement Community
Provider Information County/Parish Anne Arundel County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 1994-01-06 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote Health Inspection Rating Footnote
Provider Information Latitude 38.9616 Latitude
Provider Information Legal Business Name 35 MILKSHAKE OPCO LLC Legal Business Name
Provider Information Location 35 MILKSHAKE LANE,ANNAPOLIS,MD,21403 Location
Provider Information Long-Stay QM Rating 5 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote Long-Stay QM Rating Footnote
Provider Information Longitude -76.503 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago Y Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 130 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 60 Number of Facilities in Chain
Provider Information Number of Fines 0 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.55530 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 1.12895 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 2 Overall Rating
Provider Information Overall Rating Footnote Overall Rating Footnote
Provider Information Ownership Type For profit - Limited Liability company Ownership Type
Provider Information Physical Therapist Staffing Footnote Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 35 MILKSHAKE LANE Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name AUTUMN LAKE HEALTHCARE AT SPA CREEK Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 010 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 5 QM Rating
Provider Information QM Rating Footnote QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 188 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 13 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 22 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2023-02-03 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 188 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 35 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 21 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2018-11-05 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 221 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 0 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 221 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 21 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.39468 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 54.5 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 1.95753 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 1.43194 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 1.82668 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.14607 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.52560 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 3.78422 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 5 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote Short-Stay QM Rating Footnote
Provider Information Special Focus Status Special Focus Status
Provider Information Staffing Rating 2 Staffing Rating
Provider Information Staffing Rating Footnote Staffing Rating Footnote
Provider Information State MD State
Provider Information Telephone Number 4102695100 Telephone Number
Provider Information Total Amount of Fines in Dollars 0.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 3.41542 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 0 Total Number of Penalties
Provider Information Total nursing staff turnover 54.9 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 196.250 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 21403 ZIP Code