12 health deficiencies
Top issue: Nursing and Physician Services (3 deficiencies)
14 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Baltimore, MD
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
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
Staffing
RN hours / resident day
0.26
Registered nurse staffing
LPN hours / resident day
1.23
Licensed practical nurse staffing
Aide hours / resident day
1.90
Nurse aide staffing
Weekend hours
3.19
Weekend nurse staffing
RN turnover
50%
Annual RN turnover
Total nurse turnover
70%
Annual nurse turnover
Quality measures
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
Survey summary
Top issue: Nursing and Physician Services (3 deficiencies)
14 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Top issue: Quality of Life and Care (9 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Resident Rights (2 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-07-11
Fire Safety
Use approved construction type or materials.
Corrected 2025-09-03
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-11
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-07-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-07-11
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-07-11
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
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-11
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-07-11
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
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-07-11
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-07-11
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2025-09-03
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-07-11
Fire Safety
Use approved construction type or materials.
Corrected 2022-06-03
Fire Safety
Provide rooms that can be unlocked from inside without a key.
Corrected 2021-07-25
Fire Safety
List the names and contact information of those in the facility.
Corrected 2021-07-25
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-07-25
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-07-25
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-07-25
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-07-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-07-25
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-07-25
Fire Safety
Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
Corrected 2021-07-25
Fire Safety
Use approved construction type or materials.
Corrected 2018-10-09
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-10-09
Fire Safety
Install proper backup exit lighting.
Corrected 2018-10-09
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-10-09
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2018-10-09
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2018-10-09
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
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
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
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-06
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-06-06
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
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
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
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-06-06
Health
Provide or obtain dental services for each resident.
Corrected 2025-06-06
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-06
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-15
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
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-01-28
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-28
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
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
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-28
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-28
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-01-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-01-28
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
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
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-01-28
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
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
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
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2021-08-13
Health
Ensure each resident receives an accurate assessment.
Corrected 2021-08-13
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
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2021-08-13
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
Health
Provide and implement an infection prevention and control program.
Corrected 2021-08-13
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-08-13
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
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2021-08-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2021-08-13
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-08-13
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
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
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2021-08-13
Health
Put firmly secured handrails on each side of hallways.
Corrected 2021-08-13
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
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
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
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
Health
Post nurse staffing information every day.
Corrected 2021-08-13
Health
Provide and implement an infection prevention and control program.
Corrected 2018-10-26
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-10-26
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-10-26
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
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
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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