Cycle 1
Health 2025-02-27 · Fire 2025-02-27
30 health deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Glen Burnie, MD
Autumn Lake Healthcare At Glen Burnie
2-star overall rating with 2-star inspections with 30 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
7355 Furnace Branch Road East, Glen Burnie, MD
(410) 766-3460
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
190
Certified beds
Average residents
173
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1994-07-01
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
Hours and turnover
RN hours / resident day
0.67
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.38
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.07
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,001
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.09
Composite VBP score used to determine payment impact.
Payment multiplier
0.9848
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.83
Baseline 20.01% · Performance 19.66% · Measure score 3.83 · Achievement 3.83 · Improvement 0.68
Healthcare-associated infections
2.13
Baseline 7.91% · Performance 7.20% · Measure score 2.13 · Achievement 2.13 · Improvement 1.95
Total nurse turnover
4.69
Performance 44.53% · Measure score 4.69 · Achievement 4.69 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.59
Baseline 3.17 hours · Performance 3.25 hours · Measure score 0.59 · Achievement 0.59 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.87% |
10.72%
4.1 pts worse
|
Worse than the National Rate · Eligible stays 338 · Observed rate 20.41% · Lower 95% interval 11.41% |
| Discharge to community | 51.23% |
50.57%
0.7 pts better
|
No Different than the National Rate · Eligible stays 322 · Observed rate 40.68% · Lower 95% interval 45.98% |
| Medicare spending per beneficiary | 1.25 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 99.09% |
95.27%
3.8 pts better
|
Numerator 217 · Denominator 219 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 219 |
| Discharge self-care score | 43.93% |
53.69%
9.8 pts worse
|
Numerator 47 · Denominator 107 |
| Discharge mobility score | 42.99% |
50.94%
7.9 pts worse
|
Numerator 46 · Denominator 107 |
| Pressure ulcers or injuries, new or worsened | 6.39% |
2.29%
4.1 pts worse
|
Numerator 14 · Denominator 219 · Adjusted rate 5.38% |
| Healthcare-associated infections requiring hospitalization | 7.2% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 187 · Observed rate 8.56% · Lower 95% interval 4.54% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 92.48% |
42%
50.5 pts better
|
Numerator 123 · Denominator 133 |
| Discharge function score | 50.47% |
56.45%
6 pts worse
|
Numerator 54 · Denominator 107 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 86 · Denominator 86 |
| Transfer of health information to patient | 96.77% |
96.28%
0.5 pts better
|
Numerator 90 · Denominator 93 |
| Resident COVID-19 vaccinations up to date | 17.53% |
25.2%
7.7 pts worse
|
Numerator 17 · Denominator 97 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.3
0.1 pts worse
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.6 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.1% |
91.9%
2.2 pts better
|
93.4%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.5% · Q2 96.5% · Q3 93.4% · Q4 90.1% · 4Q avg 94.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.4% |
96.6%
0.8 pts better
|
95.5%
1.9 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
2.3%
1.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.0% · Q3 0.0% · Q4 0.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 40.2% |
21.4%
18.8 pts worse
|
11.4%
28.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 50.0% · Q3 60.9% · Q4 31.0% · 4Q avg 40.2% |
| 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 7.6% · Q2 5.7% · Q3 1.6% · Q4 4.5% · 4Q avg 4.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 11.5% |
16.1%
4.6 pts better
|
19.6%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 11.8% · Q3 11.1% · Q4 10.4% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
15.3%
9.9 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 5.7% · Q3 2.1% · Q4 5.4% · 4Q avg 5.4% · 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 | 31.0% |
26.6%
4.4 pts worse
|
16.3%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 47.9% · Q2 22.7% · Q3 24.9% · Q4 30.0% · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 30.6% |
22.9%
7.7 pts worse
|
14.9%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.6% · Q2 33.6% · Q3 30.7% · Q4 27.0% · 4Q avg 30.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.7%
0.2 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 2.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.9% |
25.4%
3.5 pts worse
|
19.8%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.5% · Q2 29.9% · Q3 28.8% · Q4 22.9% · 4Q avg 28.9% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
6.3%
1.3 pts better
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 5.8% · Q3 6.1% · Q4 4.2% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 56.7% |
78.4%
21.7 pts worse
|
81.7%
25 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 52.3% · Q3 57.4% · Q4 71.6% · 4Q avg 56.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.1% |
9.9%
1.8 pts better
|
12.0%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.1% · Observed 9.2% · Expected 12.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.3%
0.8 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.9% · Q3 2.1% · Q4 0.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 62.0% |
80.6%
18.6 pts worse
|
79.7%
17.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 62.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
21.2%
1.5 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 28.8% · Expected 30.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-11 · Fire 2019-12-11
38 health deficiencies
Top issue: Resident Rights (9 deficiencies)
11 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2018-06-15 · Fire 2018-06-15
55 health deficiencies
Top issue: Resident Rights (15 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-27
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-02-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-02-27
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-02-27
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-02-27
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-04-30
F · Potential for more than minimal harm
2025-02-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-02-27
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-02-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-30
E · Potential for more than minimal harm
2025-02-27
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-02-27
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-02-27
K321 · Smoke Deficiencies
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 2025-04-30
D · Potential for more than minimal harm
2025-02-27
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-04-30
D · Potential for more than minimal harm
2025-02-27
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-30
E · Potential for more than minimal harm
2019-12-11
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2019-12-07
E · Potential for more than minimal harm
2019-12-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-12-07
E · Potential for more than minimal harm
2019-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-07
E · Potential for more than minimal harm
2019-12-11
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-12-07
D · Potential for more than minimal harm
2019-12-11
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2019-12-07
D · Potential for more than minimal harm
2019-12-11
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 2019-12-07
D · Potential for more than minimal harm
2019-12-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-12-07
D · Potential for more than minimal harm
2019-12-11
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-12-07
D · Potential for more than minimal harm
2019-12-11
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2019-12-07
D · Potential for more than minimal harm
2019-12-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-12-07
D · Potential for more than minimal harm
2019-12-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-27
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 2025-04-11
E · Potential for more than minimal harm
2025-02-27
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-27
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 2025-04-11
E · Potential for more than minimal harm
2025-02-27
F868 · Administration Deficiencies
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-27
F941 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Corrected 2025-04-11
E · Potential for more than minimal harm
2025-02-27
F946 · Administration Deficiencies
Health
Provide training in compliance and ethics.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
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 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
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 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
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 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
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 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
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 2025-04-11
D · Potential for more than minimal harm
2025-02-27
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 2025-04-11
D · Potential for more than minimal harm
2025-02-27
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 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
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 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-02-27
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2025-04-11
C · Minimal harm
2025-02-27
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-04-11
E · Potential for more than minimal harm
2023-08-03
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 2023-09-29
E · Potential for more than minimal harm
2023-08-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
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 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
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 2023-09-29
D · Potential for more than minimal harm
2023-08-03
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 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-08-03
F725 · Nursing and Physician Services Deficiencies
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 2023-09-29
D · Potential for more than minimal harm
2023-08-03
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 2023-09-29
E · Potential for more than minimal harm
2019-12-11
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2020-01-21
E · Potential for more than minimal harm
2019-12-11
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 2020-01-21
E · Potential for more than minimal harm
2019-12-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-01-21
E · Potential for more than minimal harm
2019-12-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-01-21
E · Potential for more than minimal harm
2019-12-11
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 2020-01-21
E · Potential for more than minimal harm
2019-12-11
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 2020-01-21
E · Potential for more than minimal harm
2019-12-11
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
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 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F608 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
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 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
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 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F714 · Nursing and Physician Services Deficiencies
Health
Ensure the physician properly assigns and delegates tasks to a physician assistant, nurse practitioner or clinical nurse specialist.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
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 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
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 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F803 · Nutrition and Dietary Deficiencies
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 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
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 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2020-01-21
D · Potential for more than minimal harm
2019-12-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2020-01-21
C · Minimal harm
2019-12-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2020-01-21
E · Potential for more than minimal harm
2018-06-15
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2018-07-30
E · Potential for more than minimal harm
2018-06-15
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2018-07-30
E · Potential for more than minimal harm
2018-06-15
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2018-07-30
E · Potential for more than minimal harm
2018-06-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-07-30
E · Potential for more than minimal harm
2018-06-15
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 2018-07-30
E · Potential for more than minimal harm
2018-06-15
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 2018-07-30
E · Potential for more than minimal harm
2018-06-15
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 2018-07-30
E · Potential for more than minimal harm
2018-06-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-07-30
E · Potential for more than minimal harm
2018-06-15
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 2018-07-30
E · Potential for more than minimal harm
2018-06-15
F741 · Quality of Life and Care Deficiencies
Health
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Corrected 2018-07-30
E · Potential for more than minimal harm
2018-06-15
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 2018-07-30
E · Potential for more than minimal harm
2018-06-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-07-30
E · Potential for more than minimal harm
2018-06-15
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 2018-07-30
E · Potential for more than minimal harm
2018-06-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-07-30
E · Potential for more than minimal harm
2018-06-15
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 2018-07-30
E · Potential for more than minimal harm
2018-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
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 2018-07-30
D · Potential for more than minimal harm
2018-06-15
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 2018-07-30
D · Potential for more than minimal harm
2018-06-15
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 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
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 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F725 · Nursing and Physician Services Deficiencies
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 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
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 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F772 · Administration Deficiencies
Health
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2018-07-30
D · Potential for more than minimal harm
2018-06-15
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2018-07-30
B · Minimal harm
2018-06-15
F568 · Resident Rights Deficiencies
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2018-07-30
B · Minimal harm
2018-06-15
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2018-07-30
B · Minimal harm
2018-06-15
F803 · Nutrition and Dietary Deficiencies
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 2018-07-30
B · Minimal harm
2018-06-15
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 2018-07-30
B · Minimal harm
2018-06-15
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2018-07-30
Penalties and ownership
What sits behind the stars
Ownership
7355 Furnace Branch Road East Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
A&R Stern Family Md7 LLC
5% Or Greater Indirect Ownership Interest · Organization
Jones, Alphonson
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
Tavakoli-Jalili, Nader
Operational/Managerial Control · Individual
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#3
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