An Investigative Report: Taking a Look Inside Spa Creek-Genesis Eldercare in Annapolis; Audit of State Documents Reveal Findings of Abuse, Medication Errors, Unsanitary Conditions

An audit of documents obtained by Report Annapolis from the State Office of Health Care Quality revealed findings of abuse, medication errors and unsanitary conditions at Spa Creek-Genesis Eldercare, a 130-bed facility located off of Hilltop Lane in Annapolis.  

According to an investigation conducted in February 2018, the facility failed to ensure that a resident was free from abuse  when the unidentified resident was restrained without a physician's order or clinical rational supporting the use of the restraint, while a staff person slept in the resident's room.  The resident was observed in the fetal position, tied with a bed sheet around the knees and waist. The investigator's report indicated the facility was unable to provide any medical records documenting the restraints, and therefore It is unclear whether or not the attending physician or family of the resident was ever notified before the restraints were applied or after they were removed.  

 A total of three staff were eventually terminated for reasons related to the incident. Report Annapolis was unable to confirm how long the restraints were applied before being removed and whether or not the abused resident is still under the facility's care.  

In a report of more than 100 pages originating from a several-days long investigation, starting October 28, 2018 until November 5, 2018, an OHCQ surveyor stated that in September 2018, facility nurses accidentally administered 5 times more of a prescribed dose of morphine sulfate (a narcotic), to a resident receiving end of life care by the facility.  
There was no opportunity for discovery of the medication discrepancy due to the resident's death, according to the investigative report, which also stated that the facility failed to properly destroy the medication once the resident died.  Investigators located the medication with the original label obscured with a different label which was found to have been placed by a facility staff.  

Further investigation determined the facility failed to give adequate responses to grievances that were presented by various residents.  Investigators spoke to three different residents who expressed concerns regarding rooms not being cleaned on a daily basis and staff failing to respond to call buttons in a timely manner.  The facility failed to ensure there was not greater than 14 hours between the residents receiving their last meal for the evening and the next scheduled meal, according to the 103 page report. 

The facility also failed to ensure that sanitary conditions were maintained in the kitchen and food was stored properly, according to the report.  An inspection of the facility's kitchen was conducted and  some of the following concerns were identified:

-a cart that contained greater than 20 trays that had dirty dishes with food on each plate that was not disposed of
-inside of the kitchen where the dishwasher is located, there was standing puddles of water observed on the floor
-dirty dishes on the counter top next to the dish washer

Last month, Report Annapolis conducted an unannounced visit to the facility. During the visit, a male and a female were able to wander various areas of the facility together for approximately 10 minutes without being questioned or stopped prior to departing.  

Report Annapolis reached out to a spokesperson for Genesis HealthCare, the facility's  parent company which is headquartered in Kennet Square Pennsylvania.  There was no response to our request for comment.  


  1. Wow my mom was just there 😢

  2. My 40 year old daughter died there in 2017. I do not believe she was checked on like she should have. For hours at at time! I feel she was not properly cared for. No one would or will listen to me! My child would still be alive if not for sIps Creek!!!

    1. Email Annapolis, they helped me.

  3. My mom was ignored after a hip replacement when she had to use the restroom. She tried to go in her own, fell and dislocated her new hip and cracked the plastic and had to have it redone. The worst part is she went to the ER at 5:30 a.m. and no one at Spa Creek called to notify my dad. I went to visit her around 5:30 that evening and found out what happened to her, she had been alone in the ER at AAMC for 12 hours and no one in our family knew about it. I checked into during them and was told we did not have a case!��

  4. suing them not during them damn autocorrect!

  5. Also my mom did not have a cellphone at the time or the awareness to ask someone to call us she was immediately given drugs for the pain and was not able to communicate with anyone in our family.

  6. Be aware of how your loved ones are being treated. Contact the State of Maryland when you see any form of abuse. I could write a book about my experience with this place. Grrrr. Years later I still can’t contain my anger over some incidents that occurred during my Mother-in-laws stay there. Thankfully the State investigated my allegations & took action immediately. We were dealing with the Genesis off Forest Dr.

  7. my mom died there dec 2018 after being up & walking up & down hall way talking to people than they found her dead in her room

  8. I know I’m late to this party! This facility was only good if you stayed on their butts. Shame, shame, shame. Stop taking jobs you do not want to do especially when someone’s life depends on it! SHAME!


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