Baltimore, MD
2-star overall rating with 2-star inspections with abuse icon flag with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
3939 Penhurst Avenue, Baltimore, MD
(410) 664-9535
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
82
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
2005-04-04
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
RN hours / resident day
0.42
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.67
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.35
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.36
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.38
CMS adjusted RN staffing hours
Adjusted total hours
3.40
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
53%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
13,327
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.53
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.63% · Performance 22.97% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.51
Baseline 5.99% · Performance 7.68% · Measure score 0.51 · Achievement 0.51 · Improvement 0
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.45
Baseline 3.31 hours · Performance 3.49 hours · Measure score 1.45 · Achievement 1.45 · Improvement 0.22
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.2% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 62 · Observed rate 12.9% · Lower 95% interval 7.79% |
| Discharge to community | 34.7% |
50.57%
15.9 pts worse
|
Worse than the National Rate · Eligible stays 44 · Observed rate 25% · Lower 95% interval 24.14% |
| Medicare spending per beneficiary | 1.27 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 62 · Denominator 62 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 62 |
| Discharge self-care score | 45.95% |
53.69%
7.7 pts worse
|
Numerator 17 · Denominator 37 |
| Discharge mobility score | 45.95% |
50.94%
5 pts worse
|
Numerator 17 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 6.45% |
2.29%
4.2 pts worse
|
Numerator 4 · Denominator 62 · Adjusted rate 3.71% |
| Healthcare-associated infections requiring hospitalization | 7.68% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 47 · Observed rate 10.64% · Lower 95% interval 3.9% |
| Staff COVID-19 vaccination coverage | 3.92% |
8.2%
4.3 pts worse
|
Numerator 4 · Denominator 102 |
| Staff flu vaccination coverage | 87.72% |
42%
45.7 pts better
|
Numerator 100 · Denominator 114 |
| Discharge function score | 59.46% |
56.45%
3 pts better
|
Numerator 22 · Denominator 37 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 40 · Denominator 40 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | 6.9% |
25.2%
18.3 pts worse
|
Numerator 2 · Denominator 29 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.3
1 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.2 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.9%
8.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
2.3%
1.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.0% |
21.4%
12.4 pts better
|
11.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 7.7% · Q3 9.6% · Q4 7.5% · 4Q avg 9.0% |
| Percentage of long-stay residents who lose too much weight | 4.7% |
5.7%
1 pts better
|
5.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 7.8% · Q3 4.8% · Q4 3.1% · 4Q avg 4.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.2% |
16.1%
7.9 pts better
|
19.6%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 7.8% · Q3 7.8% · Q4 7.7% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.2% |
15.3%
5.1 pts better
|
16.7%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 10.0% · Q3 11.8% · Q4 9.3% · 4Q avg 10.2% · 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 need for help with daily activities has increased | 27.1% |
22.9%
4.2 pts worse
|
14.9%
12.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 32.7% · Q3 29.1% · Q4 20.4% · 4Q avg 27.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.7%
About the same
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.0% · Q4 0.7% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
1.5%
1.8 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 2.9% · Q3 1.5% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.3% |
25.4%
0.1 pts better
|
19.8%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 31.1% · Q3 24.3% · Q4 15.1% · 4Q avg 25.3% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
6.3%
1.6 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.0% · Q3 7.3% · Q4 3.0% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.2% |
78.4%
12.8 pts better
|
81.7%
9.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 88.2% · Q3 85.4% · Q4 95.0% · 4Q avg 91.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.9% |
9.9%
1 pts worse
|
12.0%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.9% · Observed 11.9% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.3%
0.8 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 4.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.1% |
80.6%
17.5 pts better
|
79.7%
18.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
21.2%
4.5 pts worse
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 28.4% · Expected 26.3% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Resident Rights (7 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Rights (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-11-04
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-09-01
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2025-09-01
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-10-29
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-09-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-09-01
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2022-06-17
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2022-06-17
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-06-17
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-06-17
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-06-17
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-06-17
Inspection history
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 2025-07-29
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-07-29
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-29
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-07-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-07-05
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-07-05
Health
Respond appropriately to all alleged violations.
Corrected 2022-07-05
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-07-05
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 2022-07-05
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-05
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 2022-07-05
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-07-05
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-05
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2022-07-05
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-07-05
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-07-05
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-07-05
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-07-05
Health
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected 2022-07-05
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 2022-07-05
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-07-05
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2022-07-05
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 2022-07-05
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 2022-07-05
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-05
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-05
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-07-05
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 2022-07-05
Health
Provide or obtain dental services for each resident.
Corrected 2022-07-05
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2022-07-05
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 2022-07-05
Health
Post nurse staffing information every day.
Corrected 2022-07-05
Health
Report COVID19 data to residents and families.
Corrected 2022-07-05
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-12-08
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 2018-12-08
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2018-12-08
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2018-12-08
Health
Respond appropriately to all alleged violations.
Corrected 2018-12-08
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2018-12-08
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 2018-12-08
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-12-08
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 2018-12-08
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-12-08
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-12-08
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2018-12-08
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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