6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Manchester, MD
4-star overall rating with 4-star inspections with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
3332 Main Street, Manchester, MD
(410) 239-7139
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
109
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.61
Registered nurse staffing
LPN hours / resident day
0.99
Licensed practical nurse staffing
Aide hours / resident day
2.54
Nurse aide staffing
Weekend hours
3.76
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
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 | 1.0% |
2.3%
1.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
21.4%
16.3 pts better
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 3.7% |
5.7%
2 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.4% |
16.1%
3.3 pts worse
|
19.6%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
15.3%
9.3 pts worse
|
16.7%
7.9 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 | 33.0% |
26.6%
6.4 pts worse
|
16.3%
16.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.9% |
22.9%
4 pts worse
|
14.9%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.5%
0.9 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
25.4%
4.4 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 2.2% |
6.3%
4.1 pts better
|
5.1%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
78.4%
20.7 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
9.9%
2.3 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.8% |
1.3%
0.5 pts worse
|
1.6%
0.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.6%
19.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.4% |
21.2%
3.8 pts better
|
23.9%
6.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Assessment and Care Planning (6 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2026-01-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-01-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-01-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-01-15
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 2026-01-15
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2026-01-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-01-15
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2026-01-15
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-05-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-23
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-06-19
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 2025-12-31
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-12-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-12-31
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-12-31
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-07-25
Health
Respond appropriately to all alleged violations.
Corrected 2025-07-25
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-06-10
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-10
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 2024-06-10
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-10
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 2024-06-10
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-06-10
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-06-10
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 2024-06-10
Health
Assess the resident when there is a significant change in condition
Corrected 2024-06-10
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-06-10
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-10
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-06-10
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 2024-06-10
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 2024-06-10
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-10
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-10
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-06-07
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-06-07
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 2019-06-07
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-06-07
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-06-07
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-06-07
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-06-07
Penalties and ownership
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
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