Autumn Lake Healthcare at Ballenger Creek

Name: Autumn Lake Healthcare at Ballenger Creek
Address: 347 BALLENGER DRIVE, Frederick, MD, 21701, US
Telephone: 3016635181

347 Ballenger Drive, Frederick, MD 21701 · Frederick County · 130 certified beds · avg 112 residents/day · certified since Dec 5, 1969

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

1/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.19

Nurse hours/resident/day (adjusted)

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

Health inspection rating: ★☆☆☆☆1/5 · 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.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Nov 15, 2022 · F-0760

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 (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jun 15, 2022 (Past Non-Compliance)

▲ Actual harm, one-off · Nov 15, 2022 · F-0689

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

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: Jan 16, 2023 (Deficient, Provider has date of correction)

All citations in the current public record (65)

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 4, 2026	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. · from a complaint
Jun 4, 2026	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, 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. · from a complaint
Nov 20, 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. · from a complaint
Nov 20, 2025	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. · from a complaint
Nov 20, 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. · from a complaint
Jun 30, 2025	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.
Jun 30, 2025	F · Potential for harm, facility-wide	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.
Jun 30, 2025	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
Jun 30, 2025	E · Potential for harm, repeated	The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way.
Jun 30, 2025	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 30, 2025	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.
Jun 30, 2025	E · Potential for harm, repeated	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. · from a complaint
Jun 30, 2025	E · Potential for harm, repeated	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Jun 30, 2025	E · Potential for harm, repeated	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.
Jun 30, 2025	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 30, 2025	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 30, 2025	D · Potential for harm, one-off	The facility did not treat residents with respect and dignity, or did not let them keep and use their own personal belongings.
Jun 30, 2025	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.
Jun 30, 2025	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.
Jun 30, 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 30, 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.
Jun 30, 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. · from a complaint
Jun 30, 2025	D · Potential for harm, one-off	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Jun 30, 2025	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.
Jun 30, 2025	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
Jun 30, 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.
Jun 30, 2025	D · Potential for harm, one-off	The facility did not provide safe and appropriate pain management for a resident who needed it.
Jun 30, 2025	D · Potential for harm, one-off	The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety.
Jun 30, 2025	D · Potential for harm, one-off	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 30, 2025	D · Potential for harm, one-off	The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint
Nov 15, 2022	▲ J · Immediate jeopardy, 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.
Nov 15, 2022	▲ G · Actual 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 15, 2022	F · Potential for harm, facility-wide	The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection.
Nov 15, 2022	F · Potential for harm, facility-wide	The facility did not observe each nurse aide's job performance or provide regular training as required.
Nov 15, 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.
Nov 15, 2022	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.
Nov 15, 2022	E · Potential for harm, repeated	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.
Nov 15, 2022	E · Potential for harm, repeated	The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle.
Nov 15, 2022	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Nov 15, 2022	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 15, 2022	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.
Nov 15, 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.
Nov 15, 2022	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 15, 2022	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.
Nov 15, 2022	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Nov 15, 2022	D · Potential for harm, one-off	The facility's activities program was not run by a qualified professional. The person directing recreation and social activities must have proper training or credentials.
Nov 15, 2022	D · Potential for harm, one-off	The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit.
Nov 15, 2022	D · Potential for harm, one-off	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.
Nov 15, 2022	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.
Nov 15, 2022	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Nov 15, 2022	D · Potential for harm, one-off	The facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them.
Nov 15, 2022	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.
Nov 15, 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.
Nov 15, 2022	B · Minimal risk, repeated	The facility did not let a resident or their legal representative see or buy copies of the resident's own records.
Nov 19, 2018	E · Potential for harm, repeated	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.
Nov 19, 2018	E · Potential for harm, repeated	The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them.
Nov 19, 2018	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.
Nov 19, 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 19, 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 19, 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 19, 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 19, 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.
Nov 19, 2018	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Nov 19, 2018	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.

Inspection trend by year

Citations from standard inspections stayed about the same across the last two inspection cycles (24 → 24).

Year	Citations	Serious (G–L)	Worst severity that year
2018	10	0	E
2022	24	2	J ▲
2025	29	0	F
2026	2	0	E

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)	3.19	3.83	3.95	bottom 19% in Maryland; bottom 21% in the U.S.
Registered Nurse hours	0.57	0.83	0.69	bottom 29% in Maryland; bottom 48% in the U.S.
Weekend total nurse staffing	2.92	3.43	3.50	bottom 25% in Maryland; bottom 26% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.52	0.63	0.48	top 50% in Maryland; top 31% in the U.S.
Total nursing staff turnover (%)	32.7	40.2	45.8	top 27% in Maryland; top 19% in the U.S.
RN turnover (%)	34.8	38.7	42.9	top 41% in Maryland; top 38% 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 3.80, RN 0.68, weekend 3.48. Staffing rating: 3/5.

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: 4/5 · short-stay residents: 5/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
347 Ballenger Holdco LLC	Organization	5% or Greater Direct Ownership Interest	100%	05/01/2021
Stern, Aryeh	Individual	Indirect Ownership Interest	NOT APPLICABLE	05/01/2021
Accurate Staffing LLC	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2021
Bennett, Allison	Individual	Operational/Managerial Control	NOT APPLICABLE	12/05/2023
Bennett, Allison	Individual	ADP of the SNF	NOT APPLICABLE	12/05/2023
Brand Sonnenschine LLP	Organization	ADP of the SNF	NOT APPLICABLE	05/01/2021
Eidlisz, Solomon	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	03/26/2025
Gluck, Rivka	Individual	Individual Is an Owner, Partner or Trustee of Any ADP of the SNF	NOT APPLICABLE	03/27/2025
Schwartz, Mark	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2021
Shah, Hemen	Individual	Operational/Managerial Control	NOT APPLICABLE	05/01/2021
Shah, Hemen	Individual	ADP of the SNF	NOT APPLICABLE	05/01/2021

Questions to ask on your visit

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

"What systems do you use to prevent medication errors, and what happens when one occurs?"
"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
"When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
"If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"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
Northampton Manor Nursing and Rehabilitation Cente	3.7 mi	Frederick, MD	★☆☆☆☆	1/5
Autumn Lake Healthcare at Glade Valley	4.2 mi	Walkersville, MD	★★☆☆☆	2/5
Frederick Crossing of Journey	5.2 mi	Frederick, MD	★★★★☆	3/5
Homewood Living Frederick	5.3 mi	Frederick, MD	★★★★★	5/5
Citizens Care and Rehabilitation Center of Frederi	5.5 mi	Frederick, MD	★★★★★	4/5
Willowbrooke Ct Skilled Care Buckingham's Choice	8.3 mi	Adamstown, MD	★★★★★	5/5
Autumn Lake Healthcare at Braddock Heights	9.3 mi	Frederick, MD	★★★★☆	4/5
Lorien Health Systems Mt Airy	10.3 mi	Mount Airy, MD	★★★★★	4/5
Mount Airy Nursing and Rehab Center	11.3 mi	Mount Airy, MD	★★☆☆☆	2/5	abuse
South Mountain Rehab Center	17.8 mi	Boonsboro, MD	★★★☆☆	3/5
Lorien Taneytown, INC	18.3 mi	Taneytown, MD	★★★☆☆	3/5
Montgomery Village Care Center	18.6 mi	Gaithersburg, MD	★★★★★	5/5

Compare this facility with the 3 closest →

All facilities in Frederick →

Facility data as of CMS processing date 2026-08-01. CCN 215001.

The Care File

Visit checklist — Autumn Lake Healthcare at Ballenger Creek

347 Ballenger Drive, Frederick, MD 21701 · 3016635181

Health inspection rating 1/5 · CMS overall 2/5· Fines (3y): $0

Most serious findings on record:

▲ Nov 15, 2022 (F-0760, Immediate jeopardy, 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.
▲ Nov 15, 2022 (F-0689, Actual 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.

Questions for the administrator:

☐ "What systems do you use to prevent medication errors, and what happens when one occurs?"
☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
☐ "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
☐ "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "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 215001 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)