Cycle 1
Health 2023-03-21 · Fire 2023-03-21
27 health deficiencies
Top issue: Resident Assessment and Care Planning (8 deficiencies)
20 fire-safety deficiencies
Top issue: Egress (6 deficiencies)
Baltimore, MD
Autumn Lake Healthcare Post-Acute Care Center
2-star overall rating with 1-star inspections with abuse icon flag with $15,593 in total fines with 27 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
5009 Frankford Avenue, Baltimore, MD
(410) 325-4000
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
225
Certified beds
Average residents
201
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
2000-05-17
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.85
Registered nurse staffing
LPN hours / resident day
0.71
Licensed practical nurse staffing
Aide hours / resident day
2.38
Nurse aide staffing
Weekend hours
3.50
Weekend nurse staffing
RN turnover
15%
Annual RN turnover
Total nurse turnover
25%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 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 | 98.9% |
91.9%
7 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
96.6%
1.4 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| 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 |
| Percentage of long-stay residents who have depressive symptoms | 51.9% |
21.4%
30.5 pts worse
|
11.4%
40.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.9% |
5.7%
2.2 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.2% |
16.1%
2.1 pts worse
|
19.6%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.5% |
15.3%
0.2 pts worse
|
16.7%
1.2 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 | 12.0% |
26.6%
14.6 pts better
|
16.3%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.8% |
22.9%
2.9 pts worse
|
14.9%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.1% |
0.7%
0.6 pts better
|
1.0%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.1% |
1.5%
1.4 pts better
|
1.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.4% |
25.4%
1 pts better
|
19.8%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
6.3%
2.9 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.4% |
78.4%
4 pts better
|
81.7%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.5% |
9.9%
4.4 pts better
|
12.0%
6.5 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 | 86.1% |
80.6%
5.5 pts better
|
79.7%
6.4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.4% |
21.2%
4.8 pts better
|
23.9%
7.5 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-04-09 · Fire 2019-04-09
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2017-11-10 · Fire 2017-11-10
3 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-03-21
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-03
F · Potential for more than minimal harm
2023-03-21
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 2023-05-03
F · Potential for more than minimal harm
2023-03-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-21
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 2023-05-03
E · Potential for more than minimal harm
2023-03-21
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-21
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 2023-05-03
E · Potential for more than minimal harm
2023-03-21
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-21
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-03
E · Potential for more than minimal harm
2023-03-21
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-21
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-21
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-21
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-21
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-05-03
D · Potential for more than minimal harm
2023-03-21
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-05-03
D · Potential for more than minimal harm
2019-04-09
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 2019-07-05
D · Potential for more than minimal harm
2019-04-09
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-04-09
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-07-05
D · Potential for more than minimal harm
2019-04-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-05
F · Potential for more than minimal harm
2017-11-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-04-24
F · Potential for more than minimal harm
2017-11-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-03-13
F · Potential for more than minimal harm
2017-11-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-04-19
F · Potential for more than minimal harm
2017-11-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-04-24
D · Potential for more than minimal harm
2017-11-10
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2018-03-30
D · Potential for more than minimal harm
2017-11-10
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2018-03-05
D · Potential for more than minimal harm
2017-11-10
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2018-03-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-20
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.
Not marked corrected
E · Potential for more than minimal harm
2025-11-24
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-23
E · Potential for more than minimal harm
2025-11-24
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-11-24
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 2025-12-23
D · Potential for more than minimal harm
2025-11-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-11-24
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-11-24
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 2025-12-23
D · Potential for more than minimal harm
2024-10-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-11-06
J · Immediate jeopardy
2023-03-21
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 2022-06-22
F · Potential for more than minimal harm
2023-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-22
F · Potential for more than minimal harm
2023-03-21
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 2023-05-22
E · Potential for more than minimal harm
2023-03-21
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 2023-05-22
E · Potential for more than minimal harm
2023-03-21
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 2023-07-05
E · Potential for more than minimal harm
2023-03-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-05-22
E · Potential for more than minimal harm
2023-03-21
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 2023-07-05
E · Potential for more than minimal harm
2023-03-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-05-22
E · Potential for more than minimal harm
2023-03-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-03-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-03-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-03-21
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 2023-05-22
D · Potential for more than minimal harm
2023-03-21
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 2023-05-22
D · Potential for more than minimal harm
2023-03-21
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 2023-05-22
D · Potential for more than minimal harm
2023-03-21
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 2023-05-22
D · Potential for more than minimal harm
2023-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-03-21
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 2023-07-05
D · Potential for more than minimal harm
2023-03-21
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 2023-05-22
D · Potential for more than minimal harm
2023-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-03-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-07-05
E · Potential for more than minimal harm
2019-04-09
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 2019-06-13
E · Potential for more than minimal harm
2019-04-09
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 2019-06-13
E · Potential for more than minimal harm
2019-04-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2019-06-13
D · Potential for more than minimal harm
2019-04-09
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 2019-06-13
D · Potential for more than minimal harm
2019-04-09
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2019-06-13
D · Potential for more than minimal harm
2019-04-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-06-13
D · Potential for more than minimal harm
2019-04-09
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-06-13
D · Potential for more than minimal harm
2019-04-09
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 2019-06-13
D · Potential for more than minimal harm
2019-04-09
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-06-13
D · Potential for more than minimal harm
2017-11-10
F243 · Resident Rights Deficiencies
Health
Provide resident groups or resident family groups with private space to meet.
Corrected 2017-12-11
D · Potential for more than minimal harm
2017-11-10
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 2017-12-11
D · Potential for more than minimal harm
2017-11-10
F431 · Pharmacy Service Deficiencies
Health
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Corrected 2017-12-11
Penalties and ownership
What sits behind the stars
$15,593
2023-03-21
Fine
Fine · fine $15,593
Fine
Ownership
Pacc Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Stern, Aryeh
5% Or Greater Indirect Ownership Interest · Individual
Meisels, Morris
5% Or Greater Indirect Ownership Interest · Individual
Siyata Dshmaya LLC
5% Or Greater Indirect Ownership Interest · Organization
Fenelon, Jason
Operational/Managerial Control · Individual
Pacc Realty Holdco LLC
5% Or Greater Mortgage Interest · Organization
Salazar, Andres
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Nearby options
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2-star overall rating with 2-star inspections with abuse icon flag with $16,042 in total fines with 20 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Good Samaritan Nursing Home Operator, LLC
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4-star overall rating with 4-star inspections with 12 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
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