Provider Name: AUTUMN LAKE HEALTHCARE AT ALICE MANOR
Address: 2095 ROCKROSE AVENUE, BALTIMORE, MD 21211
Phone: (410) 889-9700
County: Baltimore City (030)
Ownership Type: For profit - Limited Liability company
Certified Beds: 105
Average Residents Per Day: 84.9 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: ALICE OPERATOR LLC
First Approved Date: February 1, 1990
Affiliated Entity: AUTUMN LAKE HEALTHCARE (56)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: None
Sprinkler System Status: Yes
Overall Rating: 1 ()
Health Inspection Rating: 2 ()
QM Rating: 4 ()
Long Stay QM Rating: 4 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 1 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.90961, LPN Staff Hours Per Day: 0.9412, RN Staff Hours Per Day: 0.4550, Licensed Staff Hours Per Day: 1.3962
Total Nurse Staff Hours Per Day, per resident: 3.30582
Weekend Nurse Staff Hours: 2.90022, Weekend RN Staff Hours: 0.4186
PT Staff Hours Per Day, per resident: 0.0638
Nurse Staff Turnover: 61.2, Nurse Turnover Note:
RN Turnover: 61.5, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.2070, Case Mix LPN Hours Per Day: 0.8784, Case Mix RN Hours Per Day: 0.5312
Adjusted Nurse Aide Hours Per Day, per resident: 1.76271, Adjusted LPN Hours Per Day: 0.7907, Adjusted RN Hours Per Day: 0.3227
Total Adjusted Nurse Hours Per Day, per resident: 2.88112
Adjusted Weekend Nurse Hours Per Day, per resident: 2.52763
Health Survey Dates and Scores: Cycle 1: 2021-06-14 (Score: 120), Cycle 2: 2018-09-12 (Score: 24), Cycle 3: 2017-05-10 (Score: 60)
Total Weighted Health Score: 78.000
Reported Incidents: 4, Substantiated Complaints: 1
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 994.10, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 2095 ROCKROSE AVENUE,BALTIMORE,MD,21211 (39.3334, -76.650)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: PASARR screening for Mental disorders or Intellectual Disabilities
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Provide routine and 24-hour emergency dental care for each resident.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Put firmly secured handrails on each side of hallways.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: 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.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Prepare residents for a safe transfer or discharge from the nursing home.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: 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.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Ensure each resident receives an accurate assessment.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Post nurse staffing information every day.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-26
Type: Health, Deficiency: Keep residents' personal and medical records private and confidential.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-26
Type: Health, Deficiency: 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-26
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-26
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-26
Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: Respond appropriately to all alleged violations.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-13
Type: Health, Deficiency: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-06-23
Type: Health, Deficiency: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-06-23
Type: Health, Deficiency: Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-06-23
Type: Health, Deficiency: Train all employees on what to do in an emergency, and carry out unannounced staff drills.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2017-06-23
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0161, Version: New
Description: Use approved construction type or materials.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-09
Type: Fire Safety, Tag: 0211, Version: New
Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-09
Type: Fire Safety, Tag: 0225, Version: New
Description: Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-09
Type: Fire Safety, Tag: 0241, Version: New
Description: Have correct number of accessible exits for each story.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-09
Type: Fire Safety, Tag: 0281, Version: New
Description: Install proper backup exit lighting.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-09
Type: Fire Safety, Tag: 0341, Version: New
Description: Install a fire alarm system that can be heard throughout the facility.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-09
Type: Fire Safety, Tag: 0362, Version: New
Description: Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2018-10-09