23 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
15 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
Rising Sun, MD
3-star overall rating with 3-star inspections with 23 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
1881 Telegraph Road, Rising Sun, MD
(410) 658-6555
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
144
Certified beds
Average residents
133
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1989-06-01
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
RN hours / resident day
0.66
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.30
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.04
CMS adjusted total nurse staffing hours
Case-mix index
1.49
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
12,469
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
12.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9811
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.53
Baseline 20.55% · Performance 19.79% · Measure score 3.53 · Achievement 3.53 · Improvement 1.64
Healthcare-associated infections
0
Baseline 7.02% · Performance 8.49% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.9
Baseline 38.21% · Performance 60.00% · Measure score 0.9 · Achievement 0.9 · Improvement 0
Adjusted total nurse staffing
0.41
Baseline 2.95 hours · Performance 3.21 hours · Measure score 0.41 · Achievement 0 · Improvement 0.41
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.46% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 452 · Observed rate 8.63% · Lower 95% interval 7.48% |
| Discharge to community | 55.89% |
50.57%
5.3 pts better
|
Better than the National Rate · Eligible stays 474 · Observed rate 52.11% · Lower 95% interval 51.2% |
| Medicare spending per beneficiary | 1.21 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.66% |
95.27%
4.4 pts better
|
Numerator 290 · Denominator 291 |
| Falls with major injury | 0.69% |
0.77%
0.1 pts better
|
Numerator 2 · Denominator 291 |
| Discharge self-care score | 44.62% |
53.69%
9.1 pts worse
|
Numerator 83 · Denominator 186 |
| Discharge mobility score | 46.24% |
50.94%
4.7 pts worse
|
Numerator 86 · Denominator 186 |
| Pressure ulcers or injuries, new or worsened | 4.12% |
2.29%
1.8 pts worse
|
Numerator 12 · Denominator 291 · Adjusted rate 3.76% |
| Healthcare-associated infections requiring hospitalization | 8.49% |
7.12%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 313 · Observed rate 8.95% · Lower 95% interval 5.92% |
| Staff COVID-19 vaccination coverage | 7.33% |
8.2%
0.9 pts worse
|
Numerator 11 · Denominator 150 |
| Staff flu vaccination coverage | 56.88% |
42%
14.9 pts better
|
Numerator 91 · Denominator 160 |
| Discharge function score | 56.45% |
56.45%
About the same
|
Numerator 105 · Denominator 186 |
| Transfer of health information to provider | 91.67% |
95.95%
4.3 pts worse
|
Numerator 165 · Denominator 180 |
| Transfer of health information to patient | 88.68% |
96.28%
7.6 pts worse
|
Numerator 47 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 30.66% |
25.2%
5.5 pts better
|
Numerator 42 · Denominator 137 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.3
0.2 pts worse
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.3 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.2
0.5 pts worse
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.9%
6 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 98.2% · Q3 96.1% · Q4 98.0% · 4Q avg 97.9% |
| 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 | 3.8% |
2.3%
1.5 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 4.5% · Q3 2.9% · Q4 4.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.6% |
21.4%
12.8 pts better
|
11.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 14.1% · Q3 4.7% · Q4 10.8% · 4Q avg 8.6% |
| Percentage of long-stay residents who lose too much weight | 4.9% |
5.7%
0.8 pts better
|
5.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 4.0% · Q3 7.3% · Q4 2.3% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.9% |
16.1%
4.8 pts worse
|
19.6%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 15.0% · Q3 15.5% · Q4 40.4% · 4Q avg 20.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.5% |
15.3%
2.8 pts better
|
16.7%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 13.0% · Q3 13.6% · Q4 13.3% · 4Q avg 12.5% · 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 | 41.8% |
26.6%
15.2 pts worse
|
16.3%
25.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.1% · Q4 50.4% · 4Q avg 41.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 29.6% |
22.9%
6.7 pts worse
|
14.9%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 36.0% · Q3 23.8% · Q4 23.8% · 4Q avg 29.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.7%
0.2 pts worse
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.6% · Q3 0.8% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
1.5%
0.4 pts worse
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.8% · Q3 1.0% · Q4 4.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.0% |
25.4%
9.6 pts worse
|
19.8%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.2% · Q2 31.2% · Q3 37.4% · Q4 29.4% · 4Q avg 35.0% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
6.3%
1.5 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 6.1% · Q3 5.6% · Q4 4.0% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.2% |
78.4%
15.8 pts better
|
81.7%
12.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.9% · Q2 94.9% · Q3 92.2% · Q4 93.6% · 4Q avg 94.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.7% |
9.9%
1.8 pts worse
|
12.0%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.7% · Observed 11.2% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.8% · Q3 0.8% · Q4 1.6% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.4% |
80.6%
14.8 pts better
|
79.7%
15.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.8% |
21.2%
3.4 pts better
|
23.9%
6.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.8% · Observed 18.5% · Expected 24.9% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (7 deficiencies)
15 fire-safety deficiencies
Top issue: Egress (5 deficiencies)
No concentrated health issue counts in this cycle.
19 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-29
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 2025-05-29
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-05-29
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-05-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-29
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-29
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-05-29
Fire Safety
Meet other general requirements.
Corrected 2025-05-29
Fire Safety
Provide sliding doors free of hazards, operable without special knowledge or effort, and meet weight requirements to set door in motion.
Corrected 2025-05-29
Fire Safety
Have exits that are accessible at all times.
Corrected 2025-05-29
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-05-29
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-05-29
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-29
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-29
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2025-05-29
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-12-30
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-12-30
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-12-30
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-12-30
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-12-30
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-12-30
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-12-30
Fire Safety
Install proper backup exit lighting.
Corrected 2022-12-30
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-12-30
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2022-12-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-12-30
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-12-30
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-30
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-12-30
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2022-12-30
Fire Safety
Meet other general requirements that are deficient.
Corrected 2022-12-30
Fire Safety
Enure that solid fuel-burning fireplaces are not in patient sleeping areas.
Corrected 2022-12-30
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-12-30
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2022-12-30
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-02-18
Inspection history
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2026-01-10
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2026-01-10
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-05-09
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-09
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-09
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 2025-05-09
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-05-09
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-05-09
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-05-09
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-05-09
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 2025-05-09
Health
Respond appropriately to all alleged violations.
Corrected 2025-05-09
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-09
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-05-09
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-05-09
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-05-09
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-09
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-05-09
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-05-09
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-05-09
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-09
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 2025-05-09
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-05-09
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2019-01-31
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2019-01-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-01-31
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 2019-01-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-01-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-01-31
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-01-31
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2019-01-31
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-01-31
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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