Compare this facility with other nursing homes in BALTIMORE
Composite Quality Score
Comprehensive rating based on CMS data, staffing, quality measures, and compliance
Quick Actions
Current Availability Estimate
Basic Information
3939 PENHURST AVENUE
BALTIMORE, MD 21215
82
88% (~10 available)
AUTUMN LAKE HEALTHCARE
Quality Ratings
Safety Information
Additional Information
215349
Medicare and Medicaid
Staffing Metrics
Higher staffing hours generally indicate better care quality. Lower turnover indicates more experienced, stable staff.
Registered Nurse (RN) Hours
Per resident per day
This Facility
0.39
hours
National Avg
0.64
hours
Total Nursing Staff Hours
RN + LPN + Nurse Aides per resident per day
This Facility
3.61
hours
National Avg
3.89
hours
Breakdown:
Staff Turnover Rate
Annual nursing staff turnover
This Facility
43.8%
National Avg
46.6%
RN Turnover: 33.3%
Understanding Staffing Metrics
Staffing hours: Higher hours generally mean more staff attention per resident. Federal minimum is 3.5 total hours per resident per day, but quality facilities often exceed 4+ hours.
Turnover: High turnover (>50%) can indicate staffing issues and affect care continuity. Lower turnover means more experienced staff familiar with residents' needs.
Detailed Quality Measures
Loading quality measures...
Loading charts...
Health Inspections & Deficiencies
Total Deficiencies
78
Inspections
3
May 6, 2022 - Health Survey
46 deficiencies cited
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
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.
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
Perform COVID19 testing on residents and staff.
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies
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.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies
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.
Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Pharmacy Service Deficiencies
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.
Quality of Life and Care Deficiencies
Provide or obtain dental services for each resident.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies
Perform COVID19 testing on residents and staff.
Infection Control Deficiencies
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Nov 1, 2018 - Health Survey
24 deficiencies cited
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Resident Rights Deficiencies
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Resident Rights Deficiencies
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Resident Rights Deficiencies
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.
Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Jul 27, 2017 - Health Survey
8 deficiencies cited
Administration Deficiencies
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Environmental Deficiencies
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Nutrition and Dietary Deficiencies
Store, cook, and serve food in a safe and clean way.
Administration Deficiencies
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Resident Rights Deficiencies
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Resident Rights Deficiencies
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Environmental Deficiencies
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Nutrition and Dietary Deficiencies
Store, cook, and serve food in a safe and clean way.
Understanding Deficiencies
Deficiencies are violations of federal health and safety standards identified during CMS inspections. They are categorized by scope (isolated, pattern, or widespread) and severity (potential for harm vs. actual harm).
Critical deficiencies involve actual harm to residents and should be carefully considered. Facilities typically have opportunities to correct deficiencies and implement preventive measures.
Understanding deficiencies: Not all deficiencies indicate poor care. Learn how to interpret health inspection results and identify serious warning signs. Read our guide on warning signs →
Penalties & Enforcement
No penalties or payment denials in the past 3 years
Key Highlights
Frequently Asked Questions
What is the quality rating for AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST?
AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST has an overall CMS rating of 2 out of 5 stars. This rating is based on health inspections, staffing levels, and quality measures reported by Medicare.
How many beds does this facility have?
AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST has 82 certified beds. The facility averages 73 residents per day, with an occupancy rate of approximately 88%.
What type of ownership does this facility have?
This facility is for profit - limited liability company owned. It is part of the AUTUMN LAKE HEALTHCARE network.
How can I contact AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST?
You can call AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST at (410)664-9535. The facility is located at 3939 PENHURST AVENUE, BALTIMORE, MD 21215.
What should I look for when choosing a nursing home?
When selecting a nursing home, consider: CMS star ratings (overall, health inspection, staffing, and quality measures), nurse staffing levels, staff turnover rates, recent health inspection results, complaint history, proximity to family, and available services. We recommend visiting facilities in person, talking to current residents and staff, and checking multiple sources of information before making your decision. Use our comprehensive tour checklist when visiting facilities.
Important Considerations for This Facility
Based on this facility's data, we recommend reading these guides to understand what to look for:
Similar Quality 2-Star Facilities in Maryland
Explore other 2-star nursing homes in Maryland with similar CMS ratings:
Other Nursing Homes in Baltimore, MD
Compare this facility with other nearby nursing homes in the area:
📚 Learn How to Evaluate Facilities
Understanding quality metrics helps you make better decisions. Check out these data-driven guides:
Understanding Star Ratings
What do CMS star ratings really mean? Data from 14,751 facilities reveals the truth.
Read Guide →Why Staffing Matters Most
Learn what RN hours, turnover rates, and nurse-to-resident ratios actually mean for care quality.
Read Guide →How to Read CMS Data
Decode quality measures, health inspections, and compliance reports like a pro.
Read Guide →Recognizing Warning Signs
Critical red flags that indicate neglect, abuse, or substandard care.
Read Guide →Facility Tour Checklist
What to look for, questions to ask, and red flags to watch for during your visit.
Read Guide →View All Guides
Comprehensive resource center for choosing quality nursing home care.
Browse All →