Cycle 1
Health 2025-05-01 · Fire 2025-05-01
12 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
14 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Baltimore, MD
Autumn Lake Healthcare At Alice Manor
3-star overall rating with 3-star inspections with 12 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
2095 Rockrose Avenue, Baltimore, MD
(410) 889-9700
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
105
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1990-02-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
60 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.26
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.19
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,013
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.32
Composite VBP score used to determine payment impact.
Payment multiplier
0.9813
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.50
Baseline 7.24% · Performance 6.79% · Measure score 3.50 · Achievement 3.50 · Improvement 1.5
Total nurse turnover
0
Baseline 56.52% · Performance 63.33% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.79
Baseline 3.21 hours · Performance 3.30 hours · Measure score 0.79 · Achievement 0.79 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.95% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 7.94% · Lower 95% interval 7.09% |
| Discharge to community | 55.05% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 44 · Observed rate 43.18% · Lower 95% interval 40.12% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 60.78% |
95.27%
34.5 pts worse
|
Numerator 31 · Denominator 51 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 51 |
| Discharge self-care score | 43.24% |
53.69%
10.4 pts worse
|
Numerator 16 · Denominator 37 |
| Discharge mobility score | 45.95% |
50.94%
5 pts worse
|
Numerator 17 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 3.92% |
2.29%
1.6 pts worse
|
Numerator 2 · Denominator 51 · Adjusted rate 2.96% |
| Healthcare-associated infections requiring hospitalization | 6.79% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 6.06% · Lower 95% interval 3.5% |
| Staff COVID-19 vaccination coverage | 2.3% |
8.2%
5.9 pts worse
|
Numerator 2 · Denominator 87 |
| Staff flu vaccination coverage | 42.62% |
42%
0.6 pts better
|
Numerator 52 · Denominator 122 |
| Discharge function score | 51.35% |
56.45%
5.1 pts worse
|
Numerator 19 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 15.63% |
25.2%
9.6 pts worse
|
Numerator 5 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.1 |
1.2
0.1 pts better
|
1.8
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
91.9%
3.6 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 94.5% · Q3 94.3% · Q4 96.4% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
96.6%
2.4 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.3%
2.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 70.3% |
21.4%
48.9 pts worse
|
11.4%
58.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 70.9% · Q2 64.3% · Q3 78.8% · Q4 66.7% · 4Q avg 70.3% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
5.7%
1.2 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.8% · Q3 1.2% · Q4 4.9% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.3% |
16.1%
10.8 pts better
|
19.6%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 3.5% · Q3 2.4% · Q4 9.8% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.2% |
15.3%
2.9 pts worse
|
16.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.2% · Q2 20.9% · Q3 14.9% · Q4 19.1% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 16.8% |
26.6%
9.8 pts better
|
16.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.7% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.7% |
22.9%
0.8 pts worse
|
14.9%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 30.3% · Q3 14.7% · Q4 20.5% · 4Q avg 23.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.3% |
1.5%
1.2 pts better
|
1.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.2% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.9% |
25.4%
5.5 pts worse
|
19.8%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 23.1% · Q3 33.0% · Q4 34.6% · 4Q avg 30.9% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
6.3%
1.4 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 4.2% · Q3 6.1% · Q4 2.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
78.4%
7.4 pts better
|
81.7%
4.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 84.1% · Q2 87.7% · Q3 82.2% · Q4 89.8% · 4Q avg 85.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.6% |
9.9%
1.3 pts better
|
12.0%
3.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.6% · Observed 9.3% · Expected 12.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 77.0% |
80.6%
3.6 pts worse
|
79.7%
2.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 77.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.6% |
21.2%
0.6 pts better
|
23.9%
3.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.6% · Observed 20.9% · Expected 24.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-06-14 · Fire 2021-06-14
37 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2018-09-12 · Fire 2018-09-12
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-01
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-01
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-09-03
F · Potential for more than minimal harm
2025-05-01
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-01
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-01
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-01
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-07-11
F · Potential for more than minimal harm
2025-05-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-05-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-05-01
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-07-11
E · Potential for more than minimal harm
2025-05-01
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-05-01
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-07-11
D · Potential for more than minimal harm
2025-05-01
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2025-09-03
D · Potential for more than minimal harm
2025-05-01
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-07-11
F · Potential for more than minimal harm
2021-06-14
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-06-03
E · Potential for more than minimal harm
2021-06-14
K221 · Egress Deficiencies
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-14
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-14
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-14
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-14
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-07-25
D · Potential for more than minimal harm
2021-06-14
K928 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2021-07-25
F · Potential for more than minimal harm
2018-09-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2018-10-09
F · Potential for more than minimal harm
2018-09-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-10-09
E · Potential for more than minimal harm
2018-09-12
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2018-10-09
D · Potential for more than minimal harm
2018-09-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-10-09
D · Potential for more than minimal harm
2018-09-12
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2018-10-09
D · Potential for more than minimal harm
2018-09-12
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2018-10-09
D · Potential for more than minimal harm
2018-09-12
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2018-10-09
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-05-01
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-06
E · Potential for more than minimal harm
2025-05-01
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-06
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
G · Actual harm
2024-11-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-11-20
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-01-28
E · Potential for more than minimal harm
2024-11-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-28
E · Potential for more than minimal harm
2024-11-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-01-28
D · Potential for more than minimal harm
2024-11-20
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-01-28
F · Potential for more than minimal harm
2021-06-14
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-14
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-14
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-14
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-14
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-14
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-14
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2021-08-13
E · Potential for more than minimal harm
2021-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2021-08-13
D · Potential for more than minimal harm
2021-06-14
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2021-08-13
C · Minimal harm
2021-06-14
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2021-08-13
C · Minimal harm
2021-06-14
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-08-13
C · Minimal harm
2021-06-14
F625 · Resident Rights Deficiencies
Health
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.
Corrected 2021-08-13
C · Minimal harm
2021-06-14
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-08-13
E · Potential for more than minimal harm
2018-09-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-26
D · Potential for more than minimal harm
2018-09-12
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-10-26
D · Potential for more than minimal harm
2018-09-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-10-26
D · Potential for more than minimal harm
2018-09-12
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2018-10-26
D · Potential for more than minimal harm
2018-09-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-10-26
Penalties and ownership
What sits behind the stars
Ownership
Alice Parent LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, Aryeh
5% Or Greater Indirect Ownership Interest · Individual
Accurate Staffing LLC
Operational/Managerial Control · Organization
Alice Building Ii, LLC
5% Or Greater Mortgage Interest · Organization
Brand Sonnenschine Llp
Operational/Managerial Control · Organization
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Serasky Price, Sholom Leib
Operational/Managerial Control · Individual
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