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Autumn Lake Healthcare at Alice Manor

2095 Rockrose Avenue, Baltimore, MD 21211 · Baltimore City County · (410) 889-9700

105 certified beds, about 99 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1990

Certified for Medicaid Certified for Medicare
Overall
3 of 5
Health inspections
3 of 5
Staffing
1 of 5
Quality measures
5 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 215215 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on May 1, 2025, inspectors cited 11 health deficiencies (the Maryland average is 17, the national average 9.2).

Of 55 health citations since September 2018, 1 was rated as actual harm or immediate jeopardy to residents.

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.18 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.11 of those hours.

69.7% of nursing staff left within the year CMS measured (Maryland average 40.2%).

CMS links it to Autumn Lake Healthcare, an affiliated group of 59 nursing homes.

Health inspections

Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.

Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.

Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit

Where its citations fall on CMS's grid

CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 55 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
35D
14E
1F
Potential for minimal harm
0A
0B
4C
April 17, 2026Complaint inspection · 1 citation
  1. D
    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.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 6, 2026
    Inspectors wroteBased on a review of facility records, interviews with staff, and interviews with residents, it was determined that the facility failed to follow its established grievance process. This failure was identified in 3 of the 22 cases reviewed (Residents #2, #51, and #91) during this recertification/complaint survey.
May 1, 2025Standard inspection, Complaint inspection · 12 citations
  1. E
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    F725 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on a review of complaints, observations, and interviews with residents and staff, it was determined that the facility failed to maintain sufficient staffing levels to meet the needs of its residents. This was evident in statements from 6 out of 10 interviewable residents (Resident #23, #29, #45, #54, #55, and #60 ), 1 of 11 complaints, and statements from nursing staff (2 out of 3) during the recertification/complaint survey.
  2. E
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on observation and staff interviews, it was determined that the facility failed to ensure proper labeling of food and that food items were not expired, as evidenced by multiple food items unlabeled and expired in the refrigerator, freezer, and pantry. This was evident during the initial tour of the kitchen during the recertification/complaint survey.
  3. D
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on observation, record review, and interviews with residents and facility staff, it was determined that the facility failed to maintain a safe environment. This was evident for 1 of 2 soiled utility rooms observed during a tour of the environment during the recertification/complaint survey. Findings Included: On 05/01/25 at 10:13 AM, during a tour of the facility during the system triggered environment task, it was observed that the soiled utility room on the first floor was unlocked, this soiled utility room contained used biohazard bags, used needle/sharps containers, used oxygen equipment and trash. On 05/01/25 at 10:47 AM, during the facility tour with the Maintenance Director (Staff #26), he was notified that the soiled utility room on the 1st floor was unlocked and was a safety concern. [...]
  4. D
    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.
    F585 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on medical record reviews and interviews with residents and staff, it was determined that the facility staff failed to provide adequate responses to grievances presented by the residents. This was evident for 2 (Resident #55, #64) of the 3 residents whose grievance records were reviewed during the recertification/complaint survey.
  5. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on observations, record review, and interviews with facility staff, it was determined that the facility failed to keep residents free from accidents and hazards, as evidenced by; 1) the failure to lock a Geri chair while a resident was using it. This was evident in 1 (Resident #75) of the 3 residents reviewed for fall risk during the recertification/complaint survey. Also, the facility failed to 2) ensure the resident's environment was free from accident hazards by failing to keep a resident's fall mat clear of other objects. This was evident for 1 (Resident # 43) of 5 residents reviewed for accidents during the recertification/complaint survey.
  6. D
    Provide safe, appropriate pain management for a resident who requires such services.
    F697 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to initiate the use of nonpharmacological methods for pain management tool on the Resident's Medication and Treatment Administration Record (MAR and TAR). This was evident in the review of 1 of 1 (Resident #49) reviewed for unnecessary medications during the recertification/complaint survey.
  7. D
    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.
    F728 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that a Certified Nursing Assistant (CNA) received the required training to become a Geriatric Nursing Assistant (GNA) within the 4-month timeframe, and that all nursing staff maintained active licenses. This was evident in 1 (Staff #20) of the 3 CNA/GNA employee records reviewed during the recertification/complaint survey.
  8. D
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on observation, review of records, and interview with staff, it was determined that the facility failed to ensure narcotics removed from the resident's supply were administered to the resident, as evidenced by staff documenting the removal of narcotics without documentation of the need for the narcotic or documentation that the narcotic was administered to the resident. This was evident for 2 (#38 and #69) of 2 residents reviewed for controlled drug administration and medication administration records reviewed during the recertification/complaint survey.
  9. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to implement behavior monitoring for residents receiving antipsychotics medications and to ensure a resident received medications as ordered. This was evident for 3 (#34, #44 and #49) out of 5 reviewed for unnecessary medications during the recertification/complaint survey.
  10. D
    Provide or obtain dental services for each resident.
    F791 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on interviews and a review of medical records, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary and recommended dental services in a timely manner. This was evident for 2 (#55, #60) of 4 residents reviewed for dental services during the recertification/complaint survey.
  11. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on observation and interviews with staff, it was determined that the facility failed to: 1) ensure staff wore appropriate personal protective equipment (PPE) for enhanced barrier precautions while administering medications, and 2) ensure nursing staff use appropriate infection control practices during medication administration. This was evident for 2 (LPN #12 and LPN #16) out of 3 staff members observed during medication administration. It was also determined that the facility failed to 3) maintain isolation precautions as ordered. This was evident for 1 (Resident #16) of 24 residents records reviewed during the recertification/complaint survey process.
  12. D
    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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) June 6, 2025
    Inspectors wroteBased on staff interview and an investigation of intake #MD00217176 it was determined that the facility staff failed to ensure all nursing staff were educated on the location of the facility's Automated External Defibrillator (AED). This was evident for 3 staff (Staff #23, 24, 25) out of 11 who were interviewed during the recertification/complaint survey.
November 20, 2024Complaint inspection · 14 citations
  1. G
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · Actual harm, isolated · found on a complaint visit · Past noncompliance: already fixed when inspectors found it
    Inspectors wroteBased on medical record review, review of pertinent facility documentation, hospital record review and staff interview, it was determined the facility failed to ensure that residents were free from significant med errors as evidenced by a resident being administered medication that was not prescribed resulting in the resident ' s hospitalization. This was evident for 1 (#16) of 3 residents reviewed for medication administration during a complaint survey. This failure resulted in actual harm to Resident #16. The facility implemented effective and thorough corrective measures following this incident and prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 3/15/24.
  2. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on complaint, observation and staff interview, it was determined that the facility staff failed to provide maintenance and housekeeping services to maintain a safe, clean, comfortable and homelike environment for the residents. This was evident for the residents residing on the first floor of the facility during a complaint survey.
  3. E
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on record review, interview, and facility document and policy review, the facility failed to report an allegation of abuse to the State Survey Agency immediately, but not later than two hours after an incident occurred for 4 (Residents #28, #37, #39, and #41) of 15 residents reviewed for abuse.
  4. E
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wrote10. Resident #41 A Comprehensive & [and] Extended Care Facilities Self-Report Form, dated 03/09/2022, revealed Resident #41 reported that on 03/08/2022 at 10:00 PM, they were kicked in the back. It was determined Geriatric Nurse Aide (GNA) #22 fit the description given by the resident of the accused staff. The resident later changed their statement to say the incident happened on 03/05/2022, and the aide pushed his knee into the resident's back. The facility's investigative file did not contain any interviews with other residents to determine the extent of the alleged abuse by GNA #22, and no information was provided on the resident census at the time or the mental status assessments of the residents on GNA #22's hall at the time of the incident. [...]
  5. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to protect the residents' rights to be free from verbal abuse from staff and sexual abuse from another resident, which affected 3 (Residents #27, #28, and #39) of 15 residents reviewed for abuse. Specifically, Resident #37 sexually abused Resident #39, and Resident #27 and Resident #28 were verbally abused by a staff member.
  6. D
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident's representative(s) in writing of the reason for transfer or discharge, along with the required notification information, in a language and manner they understand and document that notification in the medical record. This was evident for 1 (#18) of 23 residents reviewed for complaints.
  7. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment (Resident #8). This was true for 1 of 20 resident complaints reviewed during a complaint survey.
  8. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on reviews of a complaint, a closed medical record and staff interview, it was determined that the facility staff failed to initiate a care plan for a resident with a history of substance abuse disorder. This was evident for 1 (Resident #24) of 20 residents reviewed during a complaint survey.
  9. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on compliant, reviews of a closed clinical record and administrative records, and staff interviews, it was determined that the facility failed to ensure that a resident received services to promote healing of a surgical wound. This was found evident in 1 (Resident #14) out of 2 Residents reviewed for wound care during a complaint survey.
  10. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on compliant, reviews of a closed clinical record and administrative records, and staff interviews, it was determined that the facility failed to ensure that a resident received services to promote healing of a pressure ulcer. This was found evident in 1 (Resident #6) out of 2 Residents reviewed for pressure ulcers during a complaint survey.
  11. D
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    F689 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to investigate a fall, determine root cause, and implement interventions to prevent further falls for 1 (Resident #40) of 1 resident reviewed for accidents.
  12. D
    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.
    F742 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on medical record review, observation and interview with resident and facility staff, it was determined that the facility failed to provide appropriate interventions for a resident with identified history of trauma. This was evident for 1 (#19) of 23 residents reviewed for complaints.
  13. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on medical record review and staff interview It was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication failing to ensure that a psychotropic medication prescribed as needed was limited to 14 days. This was evident for 1 (#17) of 23 residents reviewed for complaints.
  14. D
    Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
    F773 · Administration · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 28, 2025
    Inspectors wroteBased on reviews of a closed medical record and staff interview, it was determined that the facility staff obtained a laboratory specimen on a resident without a physician's order. This was evident for 1 (Resident #14) of 20 complaints reviewed during a complaint survey.
June 14, 2021Standard inspection · 23 citations
  1. F
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    F756 · Pharmacy Service · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on review of medical records and interview with staff, it was determined that the facility failed to have an effective system in place to 1) ensure that drug regimen reviews were done for all residents at least monthly, 2) ensure tht pharmacist recommendations were acted upon timely from identified irregularities during the monthly pharmacy review and 3) have evidence that drug regimen reviews were completed, addressed and acted on by the physician. This was evident for 4 (#32, #31, #54, #9) out of the 5 residents reviewed for medication regimen review during the annual survey but affected all residents in the facility.
  2. E
    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.
    F584 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This was observed on 1 of 2 nursing units during the annual survey.
  3. E
    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.
    F622 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to document that information was provided to the acute care facility when a resident was transferred there emergently. This was evident for 2 (#229, #129) of 5 residents reviewed for transfer to an acute care facility.
  4. E
    Prepare residents for a safe transfer or discharge from the nursing home.
    F624 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 2 (#229, #233) of 5 residents reviewed for hospitalization during the annual survey.
  5. E
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#32) of 5 residents reviewed for unnecessary medications and 2 (#232, #233) of 5 residents reviewed for hospitalization during the annual survey.
  6. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wrote5). This surveyor interviewed Resident #65 on 6/3/21 at 12:57 PM. The resident stated that he/she was not consulted with plan of care changes. A review of Resident #65's clinical record on 6/11/21 revealed that the resident had a care plan meeting on 2/3/21, but the resident was not invited. The Assistant Director of Nursing and Social worker were interviewed on 6/11/21 at 1:06 PM. She confirmed that the invitations sent to the responsible party and the resident were not in the chart. It was not evident that the resident was invited. The Administrator, Director of Nursing, and ADON were informed of the findings on 6/11/21 at 1:30 PM. [...]
  7. E
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    F804 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on resident interview, staff interview, and observation, it was determined that the facility staff failed to ensure food was served in a palatable manner. This was evident for 2 (#30, #329) out of 3 residents reviewed for complaints about food.
  8. E
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on administrative record review, medical record review, observation and interviews with facility staff, it was determined the facility 1) failed to document in the resident medical record that pain medication was refused when offered to a resident for their complaints of pain 2) failed to provide the correct Advanced Beneficiary Notice to residents who received Medicare Part A services, 3) failed to protect resident medical information, 4) failed to accurately document when a treatment was or was not done and 5) failed to timely write a progress note. This was found to be evident for 7 ( #179, #331, #332, #333, #132, #32, #229) 60 residents reviewed and for 9 resident room numbers of 60 residents reviewed during the annual survey
  9. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on observations and interviews with facility staff, it was determined that the facility failed to adhere to infection control practices and guidelines to prevent the transmission and spread of germs and microorganisms in the facility. This was found to be evident during the facility's annual Medicare/Medicaid survey.
  10. D
    PASARR screening for Mental disorders or Intellectual Disabilities
    F645 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to ensure that a PASARR was completed for the residents (Resident #31). This was evident for 1 out of 2 residents reviewed for PASARR compliance.
  11. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to develop and initiate a comprehensive, for a resident that was resident centered and specific to the resident's needs. This was evident for 1 (#32) of 5 residents reviewed for mobility and 1 (#79) of 16 residents reviewed in relation to complaints during an annual survey.
  12. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility staff failed to ensure that activities of daily living (ADL's) were provided to residents who needed assistance (Resident #31). This was evident for 1 out of 4 residents reviewed for ADL care.
  13. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on observation, record review and staff interview, it was determined that facility staff failed to provide care and treatment to Resident #32 in accordance with physician's orders and then signed off that the treatment was performed. This was evident for 1 (#32) of 5 residents reviewed for mobility.
  14. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on record review, observation and interview, it was determined the facility staff failed to provide the necessary treatment and services to promote healing and prevent infection to an existing pressure ulcer for Resident #46. This was evident for 1 (#46) of 4 residents reviewed for pressure ulcers during the annual survey.
  15. D
    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.
    F688 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on observation, record review and staff interview, it was determined that the facility failed to ensure that residents with limited range of motion received the appropriate treatment and services to prevent further decline in range of motion. This was evident for 2 (#46, #233) of 5 residents reviewed for positioning and mobility during the annual survey.
  16. D
    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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure resident receiving antipsychotic medication had a gradual dose reduction (GDR) review conducted by licensed pharmacist. This was evident for 1(#9) out 5 residents reviewed for unnecessary medications during the survey.
  17. D
    Provide routine and 24-hour emergency dental care for each resident.
    F790 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on medical record review and interview, the facility failed to provide medically ordered routine dental care to a resident (Resident #1). This was evident in 1 of 60 residents reviewed during the facility's annual survey.
  18. D
    Put firmly secured handrails on each side of hallways.
    F924 · Environmental · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on observation and staff interview, it was determined the facility failed to equip and maintain secure handrails on 2 of 2 nursing units observed during the annual survey.
  19. D
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    F943 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on review of facility employee's training files and staff interview, it was determined that the facility failed to ensure that all employees received mandatory abuse prevention training. This was evident for 1 out 5 employee's human resource records reviewed during the survey.
  20. C
    Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
    F559 · Resident Rights · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to provide a resident and the resident's responsible party with a written notice and reason for a room change before the resident was moved to a different room. This was evident for 2 (#233, #12,) of 9 residents reviewed for abuse and 1(#330) of 4 residents reviewed for discharge during an annual recertification survey, however the deficient practice affected all residents as the facility staff were not aware of the regulation
  21. C
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    F623 · Resident Rights · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteto notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (#229, #232, #233, #74) of 5 residents reviewed for hospitalization.
  22. C
    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.
    F625 · Resident Rights · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 3 (#229, #232, #233) of 5 residents reviewed for hospitalization.
  23. C
    Post nurse staffing information every day.
    F732 · Nursing and Physician Services · No actual harm, potential for minimal harm, widespread · Corrected (the home has a date of correction) August 13, 2021
    Inspectors wroteBased on observations, review of daily staffing records, and staff interview, it was determined that the facility failed to post the total number and actual hours worked by categories of Registered Nurses (RN), Licensed Practical Nurses(LPN), and Certified Geriatric Nurse Aides (GNA) per shift. This was evident on 2 of 2 nursing units observed.
September 12, 2018Standard inspection · 5 citations
  1. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) October 26, 2018
    Inspectors wroteBased on observation and staff interview, the facility staff failed to store linen in an appropriate manner to prevent the spread of infection. This practice was observed on an outside location of the building during the survey process.
  2. D
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    F550 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 26, 2018
    Inspectors wroteBased on observation the facility staff failed to maintain dignity for Resident #24 while bathing the resident in the resident's bedroom. This was evident for 1 out of 30 residents investigated during the survey process.
  3. D
    Keep residents' personal and medical records private and confidential.
    F583 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 26, 2018
    Inspectors wroteBased on medication cart observations and staff interviews it was determined the facility staff failed to ensure that the medical records were kept in a confidential manner. This was evident in 1 out of 3 medication carts.
  4. D
    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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 26, 2018
    Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure that glucose test strips and medications used for treatments were properly labeled. This was evident in 2 of 13 storage areas inspected during the survey.
  5. D
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) October 26, 2018
    Inspectors wroteBased on meal service observations and staff interviews it was determined that the facility staff: 1) failed to demonstrate appropriate hand hygiene practices during meal service involving residents on the 200 Nursing Unit. This was evident for one 1 out of 3 units, and 2) failed to install plumbing in a manner that ensures that food contact equipment is not contaminated in case of a sewage blockage.

Fire safety inspections

31 fire safety citations on file: 14 on May 1, 2025, 10 on June 14, 2021, 7 on September 12, 2018.

Every fire safety citation31 citations
  1. F
    Establish an Emergency Preparedness Program (EP).
    E 1 · May 1, 2025 · Corrected (the home has a date of correction)
  2. F
    Use approved construction type or materials.
    K 161 · May 1, 2025 · Corrected (the home has a date of correction)
  3. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · May 1, 2025 · Corrected (the home has a date of correction)
  4. F
    Properly provide smoke detection systems in areas open to corridors.
    K 347 · May 1, 2025 · Corrected (the home has a date of correction)
  5. F
    Have simulated fire drills held at unexpected times.
    K 712 · May 1, 2025 · Corrected (the home has a date of correction)
  6. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · May 1, 2025 · Corrected (the home has a date of correction)
  7. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · May 1, 2025 · Corrected (the home has a date of correction)
  8. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · May 1, 2025 · Corrected (the home has a date of correction)
  9. E
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · May 1, 2025 · Corrected (the home has a date of correction)
  10. E
    Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
    K 223 · May 1, 2025 · Corrected (the home has a date of correction)
  11. E
    Have restrictions on the use of portable space heaters.
    K 781 · May 1, 2025 · Corrected (the home has a date of correction)
  12. D
    Have stairways and smokeproof enclosures used as exits that meet safety requirements.
    K 225 · May 1, 2025 · Corrected (the home has a date of correction)
  13. D
    Have correct number of accessible exits for each story.
    K 241 · May 1, 2025 · Corrected (the home has a date of correction)
  14. D
    Meet requirements for the use of electrical equipment.
    K 919 · May 1, 2025 · Corrected (the home has a date of correction)
  15. F
    Use approved construction type or materials.
    K 161 · June 14, 2021 · Waiver
  16. E
    Provide rooms that can be unlocked from inside without a key.
    K 221 · June 14, 2021 · Corrected (the home has a date of correction)
  17. D
    List the names and contact information of those in the facility.
    E 30 · June 14, 2021 · Corrected (the home has a date of correction)
  18. D
    Establish staff and initial training requirements.
    E 37 · June 14, 2021 · Corrected (the home has a date of correction)
  19. D
    Have stairways and smokeproof enclosures used as exits that meet safety requirements.
    K 225 · June 14, 2021 · Corrected (the home has a date of correction)
  20. D
    Provide properly protected cooking facilities.
    K 324 · June 14, 2021 · Corrected (the home has a date of correction)
  21. D
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · June 14, 2021 · Corrected (the home has a date of correction)
  22. D
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · June 14, 2021 · Corrected (the home has a date of correction)
  23. D
    Meet requirements for the use of electrical equipment.
    K 919 · June 14, 2021 · Corrected (the home has a date of correction)
  24. D
    Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled.
    K 928 · June 14, 2021 · Corrected (the home has a date of correction)
  25. F
    Use approved construction type or materials.
    K 161 · September 12, 2018 · Corrected (the home has a date of correction)
  26. F
    Install a fire alarm system that can be heard throughout the facility.
    K 341 · September 12, 2018 · Corrected (the home has a date of correction)
  27. E
    Install proper backup exit lighting.
    K 281 · September 12, 2018 · Corrected (the home has a date of correction)
  28. D
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · September 12, 2018 · Corrected (the home has a date of correction)
  29. D
    Have stairways and smokeproof enclosures used as exits that meet safety requirements.
    K 225 · September 12, 2018 · Corrected (the home has a date of correction)
  30. D
    Have correct number of accessible exits for each story.
    K 241 · September 12, 2018 · Corrected (the home has a date of correction)
  31. D
    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
    K 362 · September 12, 2018 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeMarylandUnited States
All nursing staff (RN, LPN and aides)3.183.873.86
Registered nurses0.110.840.69
All nursing staff on weekends2.903.473.42
Nurse aides1.88
Licensed practical nurses1.19
Nursing staff turnover (share who left in a year)69.7%40.2%45.8%
Registered nurse turnover50.0%38.7%42.9%
Administrators who left0

CMS expects 3.97 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.30 on weekdays and 2.90 on weekends, 12% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 31.7% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.57 in April to June 2025 to 3.18 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.180.113.302.90 31.7%0 of 9099
Oct to Dec 20253.260.203.343.05 36.5%0 of 9295
Jul to Sep 20253.390.263.463.19 42.8%0 of 9290
Apr to Jun 20253.570.203.703.23 52.7%0 of 9192
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Maryland, Jan to Mar 20263.730.743.883.348.0%0.1% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.

Official wage estimates for Maryland

JobMedianMiddle halfEmployed
Maryland, all employers
CNAs (nursing assistants)$20.79$18.46 to $22.0027,720
LPNs and LVNs$35.89$31.40 to $38.309,560
Registered nurses$47.98$40.26 to $51.6152,910
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

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For Autumn Lake Healthcare at Alice Manor. No name, email or phone, and nothing you could type about a resident: every answer is a number or a choice.

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Every report is reviewed before it counts; what it says about the home never decides whether it counts. How pay reports are handled.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeMarylandUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
18.120.413.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
0.00.50.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
0.61.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
0.02.43.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
0.01.11.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
10.322.214.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
3.05.94.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
12.113.815.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
25.321.023.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
8.69.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
0.71.31.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.31.21.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Autumn Lake Healthcare at Alice Manor's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (55.0% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

55.0% this home

No different from the national rate

US median of homes 51.5% · Maryland: 90 better, 29 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 44 eligible stays.

Potentially preventable readmissions

9.9% this home

No different from the national rate

US median of homes 10.7% · Maryland: 0 better, 41 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 63 eligible stays.

Infections that led to a hospital stay

6.8% this home

No different from the national rate

US median of homes 7.1% · Maryland: 5 better, 6 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 33 eligible stays.

Self-care and mobility at discharge

62.2% this home

Median of homes: Maryland61.2% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 37 residents counted.

Falls with major injury

0.0% this home

Median of homes: Maryland0.4% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 53 residents counted.

New or worsened pressure ulcers

2.6% this home

Median of homes: Maryland2.4% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 53 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Maryland98.1% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 19 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: ALICE OPERATOR LLC. CMS links this home to Autumn Lake Healthcare, a group of 59 nursing homes averaging 2.9 stars overall.

NameRoleTypeShareSince
Alice Parent LLC5% or greater direct ownership interestOrganization100%09/01/2014
Alice Building II, LLC5% or greater mortgage interestOrganization09/01/2014
Schwartz, MarkCorporate officerIndividual01/01/2025
Accurate Staffing LLCOperational/managerial controlOrganization09/01/2014
Brand Sonnenschine LLPOperational/managerial controlOrganization09/01/2014
Schwartz, MarkOperational/managerial controlIndividual09/01/2014
Serasky Price, Sholom LeibOperational/managerial controlIndividual06/15/2021
Accurate Staffing LLCAdp of the SNFOrganization05/19/2025
Alice Building II, LLCAdp of the SNFOrganization09/01/2014
Brand Sonnenschine LLPAdp of the SNFOrganization02/25/2025
Rizqui, IbrahimAdp of the SNFIndividual01/01/2021
Serasky Price, Sholom LeibAdp of the SNFIndividual06/15/2021
Stern, AryehAdp of the SNFIndividual09/01/2014

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 13 problems in this area, most recently on April 17, 2026: "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."
  2. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 12 problems in this area, most recently on May 1, 2025: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 7 problems in this area, most recently on May 1, 2025: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
  4. When is the care plan meeting, and can family attend it?Inspectors cited 7 problems in this area, most recently on November 20, 2024: "Ensure each resident receives an accurate assessment."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 2.90 hours per resident per day, below the Maryland average of 3.47.

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Maryland contacts for a concern about a nursing home

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Common questions

What is Autumn Lake Healthcare at Alice Manor's Medicare star rating?
CMS rates Autumn Lake Healthcare at Alice Manor 3 out of 5 stars overall, with 3 for health inspections, 1 for staffing and 5 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Autumn Lake Healthcare at Alice Manor get at its last inspection?
11 health deficiencies at the standard inspection on May 1, 2025. The Maryland average is 17.
Has Autumn Lake Healthcare at Alice Manor been fined?
CMS lists no fines in the last three years.
Does Autumn Lake Healthcare at Alice Manor accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Autumn Lake Healthcare at Alice Manor?
CMS lists 13 owners and managers, and links the home to Autumn Lake Healthcare. Legal business name: ALICE OPERATOR LLC.

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