Cycle 1
Health 2024-03-05 · Fire 2024-03-05
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
19 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cambridge, MD
Autumn Lake Healthcare At Chesapeake Woods
4-star overall rating with 4-star inspections with $50,879 in total fines with 12 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
525 Glenburn Avenue, Cambridge, MD
(410) 221-1400
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
95
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1990-07-25
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.71
Registered nurse staffing
LPN hours / resident day
0.63
Licensed practical nurse staffing
Aide hours / resident day
2.71
Nurse aide staffing
Weekend hours
3.73
Weekend nurse staffing
RN turnover
44%
Annual RN turnover
Total nurse turnover
43%
Annual nurse turnover
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 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.2
0.9 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| 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 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
2.3%
1.4 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
21.4%
18.4 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.0% |
5.7%
4.7 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.2% |
16.1%
5.1 pts worse
|
19.6%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 10.7% |
15.3%
4.6 pts better
|
16.7%
6 pts better
|
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 | 37.6% |
26.6%
11 pts worse
|
16.3%
21.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.1% |
22.9%
9.2 pts worse
|
14.9%
17.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.7%
0.4 pts worse
|
1.0%
0.1 pts worse
|
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 | 26.2% |
25.4%
0.8 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
6.3%
0.1 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.8% |
78.4%
16.4 pts better
|
81.7%
13.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
9.9%
0.3 pts worse
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.9% |
1.3%
1.6 pts worse
|
1.6%
1.3 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.9% |
80.6%
11.3 pts better
|
79.7%
12.2 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.3% |
21.2%
4.1 pts worse
|
23.9%
1.4 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-03-29 · Fire 2019-03-29
21 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
5 fire-safety deficiencies
Top issue: Miscellaneous (2 deficiencies)
Cycle 3
Health 2017-11-03 · Fire 2017-11-03
8 health deficiencies
Top issue: Environmental (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-05
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-03-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-03-05
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-03-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-04-23
F · Potential for more than minimal harm
2024-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-05
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-05
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 2024-04-23
E · Potential for more than minimal harm
2024-03-05
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-23
E · Potential for more than minimal harm
2024-03-05
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-04-23
D · Potential for more than minimal harm
2024-03-05
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-23
F · Potential for more than minimal harm
2019-03-29
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2019-08-10
F · Potential for more than minimal harm
2019-03-29
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-08-10
D · Potential for more than minimal harm
2019-03-29
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-08-10
D · Potential for more than minimal harm
2019-03-29
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-08-10
D · Potential for more than minimal harm
2019-03-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-08-10
D · Potential for more than minimal harm
2017-11-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2017-10-05
D · Potential for more than minimal harm
2017-11-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2017-10-05
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Not marked corrected
E · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-05
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-05
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
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 2024-04-30
D · Potential for more than minimal harm
2024-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-30
F · Potential for more than minimal harm
2019-03-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-29
E · Potential for more than minimal harm
2019-03-29
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-03-29
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 2019-05-29
D · Potential for more than minimal harm
2019-03-29
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-03-29
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 2019-05-29
D · Potential for more than minimal harm
2019-03-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-03-29
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 2019-05-29
D · Potential for more than minimal harm
2019-03-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-03-29
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 2019-05-29
D · Potential for more than minimal harm
2019-03-29
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-03-29
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 2019-05-29
D · Potential for more than minimal harm
2019-03-29
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-03-29
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2019-05-29
D · Potential for more than minimal harm
2019-03-29
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 2019-05-29
D · Potential for more than minimal harm
2019-03-29
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-05-29
D · Potential for more than minimal harm
2017-11-03
F278 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment by a qualified health professional.
Corrected 2017-12-18
D · Potential for more than minimal harm
2017-11-03
F282 · Quality of Life and Care Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2017-12-18
D · Potential for more than minimal harm
2017-11-03
F309 · Quality of Life and Care Deficiencies
Health
Provide necessary care and services to maintain or improve the highest well being of each resident .
Corrected 2017-12-18
D · Potential for more than minimal harm
2017-11-03
F329 · Pharmacy Service Deficiencies
Health
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Corrected 2017-12-18
D · Potential for more than minimal harm
2017-11-03
F371 · Nutrition and Dietary Deficiencies
Health
Store, cook, and serve food in a safe and clean way.
Corrected 2017-12-18
D · Potential for more than minimal harm
2017-11-03
F441 · Environmental Deficiencies
Health
Have a program that investigates, controls and keeps infection from spreading.
Corrected 2017-12-18
D · Potential for more than minimal harm
2017-11-03
F456 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2017-12-18
D · Potential for more than minimal harm
2017-11-03
F514 · Administration Deficiencies
Health
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Corrected 2017-12-18
Penalties and ownership
What sits behind the stars
$14,082
2025-12-09
Fine
Fine · fine $14,082
Fine
$36,797
2024-05-02
Fine
Fine · fine $36,797
Fine
Ownership
525 Glenburn Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
A&R Stern Family Md1 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hatzlacha Rabbah LLC
5% Or Greater Indirect Ownership Interest · Organization
Borodulia, Nicholas
Operational/Managerial Control · Individual
Kramer, Amanda
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
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#3
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2-star overall rating with 2-star inspections with abuse icon flag with 7 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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