Cycle 1
Health 2025-06-30 · Fire 2025-06-30
29 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
7 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Frederick, MD
Autumn Lake Healthcare At Ballenger Creek
2-star overall rating with 1-star inspections with 28 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
347 Ballenger Drive, Frederick, MD
(301) 663-5181
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
115
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1969-12-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
60 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.64
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.09
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.73
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.46
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.19
CMS adjusted total nurse staffing hours
Case-mix index
1.60
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,443
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
49.75
Composite VBP score used to determine payment impact.
Payment multiplier
1.0038
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.41
Baseline 16.58% · Performance 18.46% · Measure score 6.41 · Achievement 6.41 · Improvement 0
Healthcare-associated infections
4.34
Baseline 5.84% · Performance 6.54% · Measure score 4.34 · Achievement 4.34 · Improvement 0
Total nurse turnover
8.40
Performance 29.36% · Measure score 8.40 · Achievement 8.40 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.75
Baseline 3.43 hours · Performance 3.29 hours · Measure score 0.75 · Achievement 0.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.78% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 379 · Observed rate 10.29% · Lower 95% interval 8.8% |
| Discharge to community | 57.05% |
50.57%
6.5 pts better
|
Better than the National Rate · Eligible stays 399 · Observed rate 53.88% · Lower 95% interval 51.53% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 99.61% |
95.27%
4.3 pts better
|
Numerator 257 · Denominator 258 |
| Falls with major injury | 0.39% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 258 |
| Discharge self-care score | 51.85% |
53.69%
1.8 pts worse
|
Numerator 98 · Denominator 189 |
| Discharge mobility score | 55.03% |
50.94%
4.1 pts better
|
Numerator 104 · Denominator 189 |
| Pressure ulcers or injuries, new or worsened | 5.04% |
2.29%
2.8 pts worse
|
Numerator 13 · Denominator 258 · Adjusted rate 4.17% |
| Healthcare-associated infections requiring hospitalization | 6.54% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 261 · Observed rate 5.75% · Lower 95% interval 4.47% |
| Staff COVID-19 vaccination coverage | 1.78% |
8.2%
6.4 pts worse
|
Numerator 3 · Denominator 169 |
| Staff flu vaccination coverage | 83.13% |
42%
41.1 pts better
|
Numerator 133 · Denominator 160 |
| Discharge function score | 62.96% |
56.45%
6.5 pts better
|
Numerator 119 · Denominator 189 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 56 · Denominator 56 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 171 · Denominator 171 |
| Resident COVID-19 vaccinations up to date | 22.56% |
25.2%
2.6 pts worse
|
Numerator 30 · Denominator 133 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.2
0.4 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.9%
7.8 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.8% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.3% |
2.3%
1 pts better
|
3.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.4% · Q4 2.5% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.7% |
21.4%
10.7 pts better
|
11.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.9% · Q3 22.2% · Q4 12.7% · 4Q avg 10.7% |
| Percentage of long-stay residents who lose too much weight | 6.4% |
5.7%
0.7 pts worse
|
5.4%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.2% · Q3 10.1% · Q4 3.9% · 4Q avg 6.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.0% |
16.1%
3.1 pts better
|
19.6%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 10.0% · Q3 13.0% · Q4 11.8% · 4Q avg 13.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
15.3%
5.6 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 10.7% · Q3 7.3% · Q4 7.0% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 50.3% |
26.6%
23.7 pts worse
|
16.3%
34 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 50.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.3% |
22.9%
6.4 pts worse
|
14.9%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 40.0% · Q3 21.9% · Q4 30.0% · 4Q avg 29.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.5%
0.5 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.7% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
25.4%
3 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.8% · Q2 23.7% · Q3 32.4% · Q4 24.4% · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 6.9% |
6.3%
0.6 pts worse
|
5.1%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 5.0% · Q3 7.0% · Q4 7.3% · 4Q avg 6.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.9% |
78.4%
8.5 pts better
|
81.7%
5.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 93.5% · Q3 83.0% · Q4 71.5% · 4Q avg 86.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
9.9%
2.5 pts better
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.1% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.6% · Q3 0.6% · Q4 0.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.4% |
80.6%
13.8 pts better
|
79.7%
14.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
21.2%
3.6 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 17.6% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-15 · Fire 2022-11-15
24 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2018-11-19 · Fire 2018-11-19
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-30
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2025-08-29
F · Potential for more than minimal harm
2025-06-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-06-30
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-06-30
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-06-30
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-08-29
E · Potential for more than minimal harm
2025-06-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-08-29
D · Potential for more than minimal harm
2025-06-30
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-08-29
D · Potential for more than minimal harm
2022-11-15
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-11-15
K331 · Smoke Deficiencies
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-11-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-15
D · Potential for more than minimal harm
2022-11-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-15
C · Minimal harm
2022-11-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2022-12-15
C · Minimal harm
2022-11-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-15
B · Minimal harm
2018-11-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-11-30
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-20
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-11-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-11-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-01-16
D · Potential for more than minimal harm
2025-11-20
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2026-01-16
F · Potential for more than minimal harm
2025-06-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-01
F · Potential for more than minimal harm
2025-06-30
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-08-01
E · Potential for more than minimal harm
2025-06-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-08-01
D · Potential for more than minimal harm
2025-06-30
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-08-01
J · Immediate jeopardy
2022-11-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-06-15
G · Actual harm
2022-11-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-11-15
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-01-16
F · Potential for more than minimal harm
2022-11-15
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-11-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-02-16
E · Potential for more than minimal harm
2022-11-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-11-15
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-11-15
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-01-16
E · Potential for more than minimal harm
2022-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-02-16
D · Potential for more than minimal harm
2022-11-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F758 · Pharmacy Service Deficiencies
Health
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.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-11-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-16
C · Minimal harm
2022-11-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-16
B · Minimal harm
2022-11-15
F573 · Resident Rights Deficiencies
Health
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
Corrected 2023-01-16
E · Potential for more than minimal harm
2018-11-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-01-02
E · Potential for more than minimal harm
2018-11-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-01-02
D · Potential for more than minimal harm
2018-11-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-01-02
D · Potential for more than minimal harm
2018-11-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-01-02
D · Potential for more than minimal harm
2018-11-19
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2019-01-02
D · Potential for more than minimal harm
2018-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-01-02
D · Potential for more than minimal harm
2018-11-19
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-01-02
D · Potential for more than minimal harm
2018-11-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2019-01-02
D · Potential for more than minimal harm
2018-11-19
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-01-02
D · Potential for more than minimal harm
2018-11-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-01-02
Penalties and ownership
What sits behind the stars
Ownership
347 Ballenger Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
A&R Stern Family Md1 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hatzlacha Rabbah LLC
5% Or Greater Indirect Ownership Interest · Organization
Bennett, Allison
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Shah, Hemen
Operational/Managerial Control · Individual
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