Autumn Lake Healthcare at Arlington West
3939 Penhurst Avenue, Baltimore, MD 21215
Autumn Lake Healthcare at Arlington West is a nursing home in Baltimore, Maryland. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
At a glance
- CMS overall star rating2 of 5
- Last standard health inspectionJune 17, 2025 (1 year ago)
- Health citations since November 1, 201848 (Maryland average 52)
- Fines in the past three yearsNone listed by CMS
- CMS flagsCMS abuse icon
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CMS flags
CMS abuse icon
CMS adds this icon when it cites a home for abuse that hurt a resident in the past year. It also adds it when it cites a home for abuse that could have hurt someone, in each of the past two years.
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 2 of 5 to 3 of 5.
Health inspection on July 6, 2026
3 citationsCMS lists this as a complaint inspection.
Show the 3 citations
Citation F0685. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Assist a resident in gaining access to vision and hearing services.
CMS lists it as corrected on August 29, 2026.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on August 29, 2026.
CMS has cited this home for F0689 2 times since 2018.
Citation F0755. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS lists it as corrected on August 29, 2026.
CMS update of February 25, 2026
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of January 14, 2026
CMS abuse icon
CMS added its abuse icon to this home.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 3 of 5 to 2 of 5.
CMS update of July 30, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Health inspection on June 17, 2025
4 citationsCMS lists this as a standard inspection and a complaint inspection.
Show the 4 citations
Citation F0584. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 29, 2025.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on July 29, 2025.
CMS has cited this home for F0600 2 times since 2022.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on July 29, 2025.
CMS has cited this home for F0609 2 times since 2018.
Citation F0760. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that residents are free from significant medication errors.
CMS lists it as corrected on July 29, 2025.
Fire safety inspection on June 17, 2025
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on November 4, 2025.
Citation E0009. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Include a process for Emergency Preparedness collaboration.
CMS lists it as corrected on September 1, 2025.
Citation E0026. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Establish roles under a Waiver declared by secretary.
CMS lists it as corrected on September 1, 2025.
Citation K0271. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have exits that are accessible at all times.
CMS lists it as corrected on October 29, 2025.
Citation K0920. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on September 1, 2025.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on September 1, 2025.
CMS update of April 30, 2025
Star rating
The CMS overall star rating changed from 1 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 1 of 5 to 2 of 5.
CMS update of February 26, 2025
Star rating
The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS staffing star rating changed from 2 of 5 to 1 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of October 30, 2024
Star rating
The CMS staffing star rating changed from 3 of 5 to 2 of 5.
CMS update of July 31, 2024
Star rating
The CMS overall star rating changed from 3 of 5 to 2 of 5.
Star rating
The CMS staffing star rating changed from 2 of 5 to 3 of 5. CMS changed how it scores this rating for many homes at once.
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
Health inspection on May 6, 2022
29 citationsCMS lists this as a standard inspection.
Show the 29 citations
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on July 5, 2022.
Citation F0550. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS lists it as corrected on July 5, 2022.
Citation F0610. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on July 5, 2022.
CMS has cited this home for F0610 2 times since 2018.
Citation F0656. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on July 5, 2022.
CMS has cited this home for F0656 2 times since 2018.
Citation F0688. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 5, 2022.
Citation F0692. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on July 5, 2022.
Citation F0756. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
CMS lists it as corrected on July 5, 2022.
Citation F0842. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS lists it as corrected on July 5, 2022.
Citation F0880. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on July 5, 2022.
Citation F0883. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS lists it as corrected on July 5, 2022.
Citation F0886. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Perform COVID19 testing on residents and staff.
CMS lists it as corrected on July 5, 2022.
Citation F0887. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
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.
CMS lists it as corrected on July 5, 2022.
Citation F0580. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
CMS lists it as corrected on July 5, 2022.
Citation F0600. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
CMS lists it as corrected on July 5, 2022.
Citation F0608. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 5, 2022.
Citation F0622. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 5, 2022.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on July 5, 2022.
CMS has cited this home for F0623 2 times since 2018.
Citation F0624. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Prepare residents for a safe transfer or discharge from the nursing home.
CMS lists it as corrected on July 5, 2022.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 5, 2022.
CMS has cited this home for F0625 2 times since 2018.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on July 5, 2022.
CMS has cited this home for F0657 2 times since 2018.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on July 5, 2022.
CMS has cited this home for F0684 2 times since 2018.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on July 5, 2022.
Citation F0690. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS lists it as corrected on July 5, 2022.
Citation F0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on July 5, 2022.
Citation F0791. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide or obtain dental services for each resident.
CMS lists it as corrected on July 5, 2022.
Citation F0921. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS lists it as corrected on July 5, 2022.
Citation F0585. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
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.
CMS lists it as corrected on July 5, 2022.
Citation F0732. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Post nurse staffing information every day.
CMS lists it as corrected on July 5, 2022.
Citation F0885. Severity C: potential for minimal harm, widespread.
The rule CMS cited:
Report COVID19 data to residents and families.
CMS lists it as corrected on July 5, 2022.
Fire safety inspection on May 6, 2022
6 citationsCMS lists this as a standard inspection.
Show the 6 citations
Citation E0006. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Conduct risk assessment and an All-Hazards approach.
CMS lists it as corrected on June 17, 2022.
Citation K0347. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly provide smoke detection systems in areas open to corridors.
CMS lists it as corrected on June 17, 2022.
Citation K0353. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on June 17, 2022.
Citation K0355. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Properly select, install, inspect, or maintain portable fire extinguishes.
CMS lists it as corrected on June 17, 2022.
Citation K0363. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install corridor and hallway doors that block smoke.
CMS lists it as corrected on June 17, 2022.
Citation K0761. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on June 17, 2022.
Health inspection on November 1, 2018
12 citationsCMS lists this as a standard inspection.
Show the 12 citations
Citation F0558. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Reasonably accommodate the needs and preferences of each resident.
CMS lists it as corrected on December 8, 2018.
Citation F0559. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS lists it as corrected on December 8, 2018.
Citation F0578. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 8, 2018.
Citation F0609. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS lists it as corrected on December 8, 2018.
Citation F0610. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Respond appropriately to all alleged violations.
CMS lists it as corrected on December 8, 2018.
Citation F0623. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on December 8, 2018.
Citation F0625. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 8, 2018.
Citation F0656. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS lists it as corrected on December 8, 2018.
Citation F0657. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS lists it as corrected on December 8, 2018.
Citation F0684. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS lists it as corrected on December 8, 2018.
Citation F0689. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS lists it as corrected on December 8, 2018.
Citation F0700. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
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.
CMS lists it as corrected on December 8, 2018.
CMS star ratings
- 2 of 5CMS overall star rating
- 2 of 5CMS health inspection star rating
- 2 of 5CMS staffing star rating
- 4 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (410) 664-9535
- Last standard health inspection
- June 17, 2025 (1 year ago)
- Certified beds
- 82
- Residents per day, on average
- 72.5
- Ownership type
- For profit - Limited Liability company
- Legal business name
- Arlington West Care Center Opco LLC
- Chain
- Autumn Lake Healthcare
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Maryland average (48 vs 52).
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- AWCC HOLDCO LLC5% or greater direct ownership interest · 100% · since 06/18/2019
- SIYATA DSHMAYA LLC5% or greater indirect ownership interest · 8% · since 06/18/2019
- GIBSON, LISAOperational/managerial control · not applicable · since 04/17/2019
- SCHWARTZ, MARKOperational/managerial control · not applicable · since 12/15/2021
Questions
When was Autumn Lake Healthcare at Arlington West last inspected?
CMS lists June 17, 2025 as the date of its most recent standard health inspection.
How many citations (violations) does Autumn Lake Healthcare at Arlington West have?
CMS lists 48 health citations since November 1, 2018. CMS also calls these deficiencies.
Has Autumn Lake Healthcare at Arlington West been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Autumn Lake Healthcare at Arlington West?
Its CMS overall star rating is 2 of 5.
Is Autumn Lake Healthcare at Arlington West a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.
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