AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST
Open-data reference.
AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST is a for profit - limited liability company facility in BALTIMORE, MD with 82 certified beds and a 2-star overall CMS rating. The facility has 45 deficiency records on file.
3939 PENHURST AVENUE, BALTIMORE, MD 21215
Phone: 4106649535
Overall Rating
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 215349
- Ownership
- For profit - Limited Liability company
- Provider Type
- Medicare and Medicaid
- Beds
- 82
- Residents
- 77
- In Hospital
- No
- County
- Baltimore City
- Last Inspection
- Jun 17, 2025
Staffing Data
- RN Hours
- 0.42 (nat'l avg: 0.68)
- LPN Hours
- 1.25
- CNA Hours
- 2.06
- Total Nursing Hours
- 3.73 (nat'l avg: 3.89)
- PT Hours
- 0.03
- Nursing Turnover
- 48.2%
- RN Turnover
- 52.9%
What the CMS Record Reveals About AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST
AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST operates 82 certified beds in BALTIMORE, MD with approximately 77 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars. The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results (2★), staffing levels (2★), and quality measures (2★). Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone — a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
The inspection file contains 45 deficiency records from recent surveys, all falling in the no-harm or minimal-harm bands of the CMS scope-and-severity grid. No fines or payment denials have been assessed against this provider, suggesting issues — if any — did not rise to the enforcement threshold. Staffing is reported at 3.73 total nursing hours per resident day (national average 3.89), with RN coverage at 0.42 per resident day — the single staffing metric most strongly tied to resident outcomes in peer-reviewed literature.
Classified as "For profit - Limited Liability company" ownership and operating as a "Medicare and Medicaid" provider, AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST falls into a category where comparative context matters. National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes — ratings and fines are lagging indicators of those upstream choices. Reported nursing turnover at this facility is 48.2%, within a range generally associated with stable care teams. For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report — the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (45 most recent)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 29, 2025
Ensure that residents are free from significant medication errors.
Category: Pharmacy Service Deficiencies
Corrected: Jul 29, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 29, 2025
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.
Category: Resident Rights Deficiencies
Corrected: Jul 29, 2025
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Category: Environmental Deficiencies
Corrected: Jul 5, 2022
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.
Category: Infection Control Deficiencies
Corrected: Jul 5, 2022
Perform COVID19 testing on residents and staff.
Category: Infection Control Deficiencies
Corrected: Jul 5, 2022
Report COVID19 data to residents and families.
Category: Infection Control Deficiencies
Corrected: Jul 5, 2022
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Category: Infection Control Deficiencies
Corrected: Jul 5, 2022
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Jul 5, 2022
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 5, 2022
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Jul 5, 2022
Provide or obtain dental services for each resident.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
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.
Category: Pharmacy Service Deficiencies
Corrected: Jul 5, 2022
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Category: Pharmacy Service Deficiencies
Corrected: Jul 5, 2022
Post nurse staffing information every day.
Category: Nursing and Physician Services Deficiencies
Corrected: Jul 5, 2022
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
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.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Jul 5, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 5, 2022
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Jul 5, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Jul 5, 2022
Prepare residents for a safe transfer or discharge from the nursing home.
Category: Resident Rights Deficiencies
Corrected: Jul 5, 2022
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Jul 5, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Jul 5, 2022
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 5, 2022
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 5, 2022
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Jul 5, 2022
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.
Category: Resident Rights Deficiencies
Corrected: Jul 5, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Category: Resident Rights Deficiencies
Corrected: Jul 5, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Jul 5, 2022
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.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 8, 2018
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 8, 2018
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 8, 2018
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 8, 2018
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 8, 2018
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.
Category: Resident Rights Deficiencies
Corrected: Dec 8, 2018
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Category: Resident Rights Deficiencies
Corrected: Dec 8, 2018
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 8, 2018
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 8, 2018
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.
Category: Resident Rights Deficiencies
Corrected: Dec 8, 2018
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Category: Resident Rights Deficiencies
Corrected: Dec 8, 2018
Reasonably accommodate the needs and preferences of each resident.
Category: Resident Rights Deficiencies
Corrected: Dec 8, 2018
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 27.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 4.7% | No |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 3.3% | Yes |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 9.0% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 91.2% | No |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 2.1% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | N/A | Yes |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 8.2% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 100.0% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 98.1% | No |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 4.7% | Yes |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 25.3% | No |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 10.2% | Yes |
Penalty History
No penalties on record.
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Frequently Asked Questions
What is the overall CMS rating for AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST?
What are the staffing levels at AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST?
How many beds does AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST have?
Does AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST have any deficiencies on record?
Has AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST received any fines or penalties?
Who owns AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST?
When was AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST last inspected?
What quality measures are tracked for AUTUMN LAKE HEALTHCARE AT ARLINGTON WEST?
Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology — how this data is sourced, computed, and verified.