Autumn Lake Healthcare at Alice Manor

Name: Autumn Lake Healthcare at Alice Manor
Address: 2095 ROCKROSE AVENUE, Baltimore, MD, 21211, US
Telephone: 4108899700

2095 Rockrose Avenue, Baltimore, MD 21211 · Baltimore City County · 105 certified beds · avg 99 residents/day · certified since Feb 1, 1990

Part of chain: AUTUMN LAKE HEALTHCARE (59 facilities, chain avg rating 2.8★)

3/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.07

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Actual harm, one-off · Nov 20, 2024 · F-0760 · triggered by a complaint

The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Why it matters: A serious medication error can cause real harm, hospitalization, or worse.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Mar 15, 2024 (Past Non-Compliance)

All citations in the current public record (55)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Apr 17, 2026	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint
May 1, 2025	E · Potential for harm, repeated	The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · from a complaint
May 1, 2025	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
May 1, 2025	D · Potential for harm, one-off	The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly.
May 1, 2025	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
May 1, 2025	D · Potential for harm, one-off	The facility did not make sure its nurse aides were properly trained — aides working more than 4 months must be trained and competent, and newer aides must be enrolled in training.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 1, 2025	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
May 1, 2025	D · Potential for harm, one-off	The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care.
May 1, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
May 1, 2025	D · Potential for harm, one-off	The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Nov 20, 2024	▲ G · Actual harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint
Nov 20, 2024	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Nov 20, 2024	E · Potential for harm, repeated	The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Nov 20, 2024	E · Potential for harm, repeated	The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not provide appropriate treatment and services to residents with a mental health condition, difficulty adjusting emotionally, or a history of trauma or post-traumatic stress disorder (PTSD). · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · from a complaint
Nov 20, 2024	D · Potential for harm, one-off	The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them. · from a complaint
Jun 14, 2021	F · Potential for harm, facility-wide	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Jun 14, 2021	E · Potential for harm, repeated	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Jun 14, 2021	E · Potential for harm, repeated	The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out.
Jun 14, 2021	E · Potential for harm, repeated	The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly.
Jun 14, 2021	E · Potential for harm, repeated	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 14, 2021	E · Potential for harm, repeated	The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Jun 14, 2021	E · Potential for harm, repeated	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Jun 14, 2021	E · Potential for harm, repeated	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Jun 14, 2021	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not provide routine dental care and 24-hour emergency dental care for residents.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not have firmly secured handrails on both sides of its hallways.
Jun 14, 2021	D · Potential for harm, one-off	The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation.
Jun 14, 2021	C · Minimal risk, facility-wide	The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand.
Jun 14, 2021	C · Minimal risk, facility-wide	The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Jun 14, 2021	C · Minimal risk, facility-wide	The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Jun 14, 2021	C · Minimal risk, facility-wide	The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day.
Sep 12, 2018	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Sep 12, 2018	D · Potential for harm, one-off	The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Sep 12, 2018	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential.
Sep 12, 2018	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Sep 12, 2018	D · Potential for harm, one-off	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (23 → 11).

Year	Citations	Serious (G–L)	Worst severity that year
2018	5	0	E
2021	23	0	F
2024	14	1	G ▲
2025	12	0	E
2026	1	0	D

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Maryland avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.07	3.83	3.95	bottom 11% in Maryland; bottom 16% in the U.S.
Registered Nurse hours	0.11	0.83	0.69	bottom 1% in Maryland; bottom 1% in the U.S.
Weekend total nurse staffing	2.80	3.43	3.50	bottom 14% in Maryland; bottom 21% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.12	0.63	0.48	bottom 1% in Maryland; bottom 2% in the U.S.
Total nursing staff turnover (%)	69.7	40.2	45.8	bottom 1% in Maryland; bottom 6% in the U.S.
RN turnover (%)	50.0	38.7	42.9	bottom 26% in Maryland; bottom 39% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.18, RN 0.11, weekend 2.90. Staffing rating: 1/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Alice Parent LLC	Organization	5% or Greater Direct Ownership Interest	100%	09/01/2014
Accurate Staffing LLC	Organization	Operational/Managerial Control	NOT APPLICABLE	09/01/2014
Accurate Staffing LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/19/2025
Alice Building II, LLC	Organization	5% or Greater Mortgage Interest	NOT APPLICABLE	09/01/2014
Alice Building II, LLC	Organization	ADP of the SNF	NOT APPLICABLE	09/01/2014
Brand Sonnenschine LLP	Organization	Operational/Managerial Control	NOT APPLICABLE	09/01/2014
Brand Sonnenschine LLP	Organization	ADP of the SNF	NOT APPLICABLE	02/25/2025
Rizqui, Ibrahim	Individual	ADP of the SNF	NOT APPLICABLE	01/01/2021
Schwartz, Mark	Individual	Corporate Officer	NOT APPLICABLE	01/01/2025
Schwartz, Mark	Individual	Operational/Managerial Control	NOT APPLICABLE	09/01/2014
Serasky Price, Sholom Leib	Individual	Operational/Managerial Control	NOT APPLICABLE	06/15/2021
Serasky Price, Sholom Leib	Individual	ADP of the SNF	NOT APPLICABLE	06/15/2021
Stern, Aryeh	Individual	ADP of the SNF	NOT APPLICABLE	09/01/2014

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What systems do you use to prevent medication errors, and what happens when one occurs?"
"Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
"What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"How do you assess and manage residents' pain, especially for those who have trouble communicating?"
"What training and competency checks do your nurse aides go through, and how do you keep their skills current?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Roland Park Rehabilitation and Healthcare Center	1.0 mi	Baltimore, MD	★★★☆☆	2/5
Northwest Healthcare Center	1.0 mi	Baltimore, MD	★★★★☆	4/5
Keswick Multi-Care Center	1.2 mi	Baltimore, MD	★★★★☆	3/5
Levindale Hebrew Ger Ctr & HSP	1.6 mi	Baltimore, MD	★★☆☆☆	2/5
Blue Point Healthcare Center	1.6 mi	Baltimore, MD	★★★☆☆	2/5
Future Care Sandtown-Winchester	1.8 mi	Baltimore, MD	★★★★☆	3/5
Autumn Lake Healthcare at Arlington West	1.8 mi	Baltimore, MD	★★☆☆☆	2/5	abuse
Autumn Lake Healthcare at Bridgepark	2.0 mi	Baltimore, MD	★★☆☆☆	2/5
Future Care Homewood	2.0 mi	Baltimore, MD	★★★★☆	4/5
Future Care Charles Village	2.1 mi	Baltimore, MD	★★★★☆	3/5
The Nursing and Rehab Center at Stadium Place	2.6 mi	Baltimore, MD	★★☆☆☆	2/5
Maryland Baptist Aged Home	2.7 mi	Baltimore, MD	★★★☆☆	3/5

Compare this facility with the 3 closest →

All facilities in Baltimore →

Facility data as of CMS processing date 2026-08-01. CCN 215215.

The Care File

Visit checklist — Autumn Lake Healthcare at Alice Manor

2095 Rockrose Avenue, Baltimore, MD 21211 · 4108899700

Health inspection rating 3/5 · CMS overall 3/5· Fines (3y): $0

Most serious findings on record:

▲ Nov 20, 2024 (F-0760, Actual harm, one-off): The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.

Questions for the administrator:

☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
☐ "What is your nurse and aide staffing ratio on each shift, including nights and weekends?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "How do you assess and manage residents' pain, especially for those who have trouble communicating?"
☐ "What training and competency checks do your nurse aides go through, and how do you keep their skills current?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 215215 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)