Autumn Lake Healthcare at Arlington West

Name: Autumn Lake Healthcare at Arlington West
Address: 3939 PENHURST AVENUE, Baltimore, MD, 21215, US
Telephone: 4106649535

3939 Penhurst Avenue, Baltimore, MD 21215 · Baltimore City County · 82 certified beds · avg 73 residents/day · certified since Apr 4, 2005

Abuse citation flag (CMS)

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

The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.

2/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.32

Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

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.

All citations in the current public record (45)

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
Jun 17, 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.
Jun 17, 2025	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
Jun 17, 2025	D · Potential for harm, one-off	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.
Jun 17, 2025	D · Potential for 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.
May 6, 2022	F · Potential for harm, facility-wide	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 6, 2022	E · Potential for harm, repeated	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.
May 6, 2022	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.
May 6, 2022	E · Potential for harm, repeated	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.
May 6, 2022	E · Potential for harm, repeated	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.
May 6, 2022	E · Potential for harm, repeated	The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
May 6, 2022	E · Potential for harm, repeated	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.
May 6, 2022	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.
May 6, 2022	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.
May 6, 2022	E · Potential for harm, repeated	The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations.
May 6, 2022	E · Potential for harm, repeated	The facility did not perform required COVID-19 testing on residents and staff.
May 6, 2022	E · Potential for harm, repeated	The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status.
May 6, 2022	D · Potential for harm, one-off	The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
May 6, 2022	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.
May 6, 2022	D · Potential for harm, one-off	The facility did not have working policies to ensure employees report any suspected crime against a resident on time, to post notices of employees' reporting rights, and to prevent retaliation against staff who report.
May 6, 2022	D · Potential for harm, one-off	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.
May 6, 2022	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.
May 6, 2022	D · Potential for harm, one-off	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.
May 6, 2022	D · Potential for harm, one-off	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.
May 6, 2022	D · Potential for harm, one-off	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.
May 6, 2022	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.
May 6, 2022	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.
May 6, 2022	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
May 6, 2022	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.
May 6, 2022	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 6, 2022	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
May 6, 2022	C · Minimal risk, facility-wide	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 6, 2022	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.
May 6, 2022	C · Minimal risk, facility-wide	The facility did not report COVID-19 data to residents and their families as required. Facilities must keep residents and families informed about COVID-19 cases.
Nov 1, 2018	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Nov 1, 2018	D · Potential for harm, one-off	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.
Nov 1, 2018	D · Potential for harm, one-off	The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Nov 1, 2018	D · Potential for harm, one-off	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.
Nov 1, 2018	D · Potential for harm, one-off	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.
Nov 1, 2018	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.
Nov 1, 2018	D · Potential for harm, one-off	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.
Nov 1, 2018	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.
Nov 1, 2018	D · Potential for harm, one-off	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.
Nov 1, 2018	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.
Nov 1, 2018	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.
Nov 1, 2018	D · Potential for harm, one-off	The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (29 → 4).

Year	Citations	Worst severity that year
2018	12	D
2022	29	F
2025	4	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)	3.32	3.83	3.95	bottom 33% in Maryland; bottom 27% in the U.S.
Registered Nurse hours	0.36	0.83	0.69	bottom 4% in Maryland; bottom 16% in the U.S.
Weekend total nurse staffing	2.92	3.43	3.50	bottom 26% in Maryland; bottom 27% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.33	0.63	0.48	bottom 14% in Maryland; bottom 39% in the U.S.
Total nursing staff turnover (%)	43.8	40.2	45.8	bottom 41% in Maryland; top 47% in the U.S.
RN turnover (%)	33.3	38.7	42.9	top 34% in Maryland; top 33% 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 3.61, RN 0.39, weekend 3.17. Staffing rating: 2/5.

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: 3/5 · long-stay residents: 4/5 · short-stay residents: 1/5

Who owns this facility

For profit - Limited Liability company

Owner / manager	Type	Role	Stake	Since
Awcc Holdco LLC	Organization	5% or Greater Direct Ownership Interest	100%	06/18/2019
Siyata Dshmaya LLC	Organization	5% or Greater Indirect Ownership Interest	8%	06/18/2019
A&r Stern Family Pa Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	02/01/2019
Accurate Staffing LLC	Organization	ADP of the SNF	NOT APPLICABLE	12/15/2021
Awcc Realty Holdco LLC	Organization	5% or Greater Mortgage Interest	NOT APPLICABLE	06/18/2019
Awcc Realty Holdco LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/18/2019
Brand Sonnenschine LLP	Organization	ADP of the SNF	NOT APPLICABLE	12/15/2021
Gibson, Lisa	Individual	Operational/Managerial Control	NOT APPLICABLE	04/17/2019
Gibson, Lisa	Individual	ADP of the SNF	NOT APPLICABLE	04/17/2019
Gluck, David	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	04/30/2025
Handler, Samuel	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	04/30/2025
Meisels, Morris	Individual	ADP of the SNF	NOT APPLICABLE	06/18/2019
Sahar, Ophir	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	04/30/2025
Schwartz, Mark	Individual	Corporate Officer	NOT APPLICABLE	03/01/2025
Schwartz, Mark	Individual	Operational/Managerial Control	NOT APPLICABLE	12/15/2021
Siyata Dshmaya LLC	Organization	ADP of the SNF	NOT APPLICABLE	06/18/2019
Stern, Aryeh	Individual	ADP of the SNF	NOT APPLICABLE	06/18/2019
Temesgen, Addisu	Individual	ADP of the SNF	NOT APPLICABLE	04/01/2021

Questions to ask on your visit

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

"Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"What systems do you use to prevent medication errors, and what happens when one occurs?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
"If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
"Can you show me an example care plan, and how are families included when it's created and updated?"
"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
Autumn Lake Healthcare at Bridgepark	0.7 mi	Baltimore, MD	★★☆☆☆	2/5
Northwest Healthcare Center	1.0 mi	Baltimore, MD	★★★★☆	4/5
Blue Point Healthcare Center	1.3 mi	Baltimore, MD	★★★☆☆	2/5
Lochearn Nursing Home, LLC	1.4 mi	Baltimore, MD	★★★★★	4/5
Levindale Hebrew Ger Ctr & HSP	1.5 mi	Baltimore, MD	★★☆☆☆	2/5
Autumn Lake Healthcare at Alice Manor	1.8 mi	Baltimore, MD	★★★☆☆	3/5
Roland Park Rehabilitation and Healthcare Center	2.3 mi	Baltimore, MD	★★★☆☆	2/5
Resorts of Augsburg	2.3 mi	Baltimore, MD	★★☆☆☆	2/5
King David Nursing and Rehabilitation Center	2.5 mi	Baltimore, MD	★★☆☆☆	2/5	abuse
Keswick Multi-Care Center	2.9 mi	Baltimore, MD	★★★★☆	3/5
Maryland Baptist Aged Home	3.1 mi	Baltimore, MD	★★★☆☆	3/5
Future Care Sandtown-Winchester	3.3 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 215349.

The Care File

Visit checklist — Autumn Lake Healthcare at Arlington West

3939 Penhurst Avenue, Baltimore, MD 21215 · 4106649535

Health inspection rating 2/5 · CMS overall 2/5 · ▲ FEDERAL ABUSE CITATION FLAG· Fines (3y): $0

Questions for the administrator:

☐ "Can we tour the resident rooms, bathrooms, and common areas today, including areas not on the usual tour route?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
☐ "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
☐ "Can you show me an example care plan, and how are families included when it's created and updated?"
☐ "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 215349 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)