Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
AUTUMN LAKE HEALTHCARE AT ALICE MANOR
BALTIMORE, MD · 105 certified beds · Last Life Safety survey May 1, 2025
CMS Certification Number 215215 · first certified February 1990
Ownership
Operated by AUTUMN LAKE HEALTHCARE · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within MD
31 citations — more than 76% of the 221 certified nursing homes in MD. Compared within MD rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 14 citations; the earlier surveys in the window averaged 8.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens October 2026. This facility’s last Life Safety survey was May 2025. Facilities in MD are typically surveyed 17–59 months after the last one (median 30), measured over 283 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 31 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
9 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 31 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0924 Put firmly secured handrails on each side of hallways.
How that compares
Compared with the median facility in MD, and nationally. Surveyors differ markedly between states, so the MD figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 31 |
| Median facility in MD | 22 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| September 12, 2018 | 7 |
| June 14, 2021 | 10 |
| May 1, 2025 | 14 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0161 | Use approved construction type or materials. | 3 | 2025-05-01 |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | 3 | 2025-05-01 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2025-05-01 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2025-05-01 |
| K-0919 | Meet requirements for the use of electrical equipment. | 2 | 2025-05-01 |
| K-0241 | Have correct number of accessible exits for each story. | 2 | 2025-05-01 |
| K-0281 | Install proper backup exit lighting. | 1 | 2018-09-12 |
| E-0030 | List the names and contact information of those in the facility. | 1 | 2021-06-14 |
What the citations cover
- Egress Deficiencies 10
- Smoke Deficiencies 7
- Gas, Vacuum, and Electrical Systems Deficiencies 5
- Miscellaneous Deficiencies 3
- Other 6
| Category | Citations |
|---|---|
| Egress Deficiencies | 10 |
| Smoke Deficiencies | 7 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Construction Deficiencies | 3 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
May 1, 2025 — 14 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (July 11, 2025) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (September 3, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0241 | Have correct number of accessible exits for each story. | Deficient, Provider has date of correction (September 3, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (July 11, 2025) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (July 11, 2025) |
June 14, 2021 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (July 25, 2021) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (July 25, 2021) |
| K-0161 | Use approved construction type or materials. | Waiver has been granted (June 3, 2022) |
| K-0221 | Provide rooms that can be unlocked from inside without a key. | Deficient, Provider has date of correction (July 25, 2021) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (July 25, 2021) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (July 25, 2021) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (July 25, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (July 25, 2021) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (July 25, 2021) |
| K-0928 | Ensure equipment listed for use in oxygen-enriched atmospheres are correctly labeled. | Deficient, Provider has date of correction (July 25, 2021) |
September 12, 2018 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (October 9, 2018) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (October 9, 2018) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (October 9, 2018) |
| K-0241 | Have correct number of accessible exits for each story. | Deficient, Provider has date of correction (October 9, 2018) |
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (October 9, 2018) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (October 9, 2018) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (October 9, 2018) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.