Cycle 1
Health 2024-07-31 · Fire 2024-07-31
23 health deficiencies
Top issue: Resident Rights (6 deficiencies)
22 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Baltimore, MD
Autumn Lake Healthcare At Long Green
2-star overall rating with 2-star inspections with 23 recent health deficiencies with 22 fire-safety deficiencies in the latest cycle
115 East Melrose Avenue, Baltimore, MD
(410) 435-9073
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1967-02-14
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
0.57
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.59
CMS adjusted RN staffing hours
Adjusted total hours
3.65
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,474
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
5.08
Baseline 8.46% · Performance 6.53% · Measure score 5.08 · Achievement 4.38 · Improvement 5.08
Total nurse turnover
3.10
Baseline 68.75% · Performance 52.94% · Measure score 3.10 · Achievement 2.63 · Improvement 3.10
Adjusted total nurse staffing
1.63
Baseline 3.42 hours · Performance 3.54 hours · Measure score 1.63 · Achievement 1.63 · Improvement 0.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.69% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 58 · Observed rate 12.07% · Lower 95% interval 7.34% |
| Discharge to community | 39.74% |
50.57%
10.8 pts worse
|
Worse than the National Rate · Eligible stays 56 · Observed rate 30.36% · Lower 95% interval 29.51% |
| Medicare spending per beneficiary | 1.48 |
1.02
0.5 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 53 · Denominator 53 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 53 |
| Discharge self-care score | 64.52% |
53.69%
10.8 pts better
|
Numerator 20 · Denominator 31 |
| Discharge mobility score | 64.52% |
50.94%
13.6 pts better
|
Numerator 20 · Denominator 31 |
| Pressure ulcers or injuries, new or worsened | 1.89% |
2.29%
0.4 pts better
|
Numerator 1 · Denominator 53 · Adjusted rate 1.55% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 29 · Observed rate 3.45% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 12.35% |
8.2%
4.2 pts better
|
Numerator 10 · Denominator 81 |
| Staff flu vaccination coverage | 98.89% |
42%
56.9 pts better
|
Numerator 178 · Denominator 180 |
| Discharge function score | 87.1% |
56.45%
30.6 pts better
|
Numerator 27 · Denominator 31 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90.91% |
96.28%
5.4 pts worse
|
Numerator 20 · Denominator 22 |
| Resident COVID-19 vaccinations up to date | 12.9% |
25.2%
12.3 pts worse
|
Numerator 4 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.9 · Expected 2.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.2 |
1.2
2 pts worse
|
1.8
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.2 · Observed 3.4 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.9%
7.6 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 99.1% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 0.7% |
2.3%
1.6 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 1.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 25.8% |
21.4%
4.4 pts worse
|
11.4%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 29.5% · Q3 26.4% · Q4 25.3% · 4Q avg 25.8% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
5.7%
1.5 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 5.5% · Q3 3.3% · Q4 4.5% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.0% |
16.1%
1.1 pts better
|
19.6%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 13.0% · Q3 19.8% · Q4 22.1% · 4Q avg 15.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
15.3%
2.9 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 14.9% · Q3 10.3% · Q4 11.6% · 4Q avg 12.4% · 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 | 10.3% |
26.6%
16.3 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 11.4% · Q3 7.6% · Q4 7.3% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.6% |
22.9%
7.3 pts better
|
14.9%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.7% · Q2 16.9% · Q3 19.5% · Q4 12.9% · 4Q avg 15.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
1.5%
0.7 pts worse
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 0.9% · Q4 3.8% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 32.1% |
25.4%
6.7 pts worse
|
19.8%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.9% · Q2 21.4% · Q3 28.0% · Q4 40.8% · 4Q avg 32.1% |
| Percentage of long-stay residents with pressure ulcers | 11.1% |
6.3%
4.8 pts worse
|
5.1%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 9.4% · Q3 10.5% · Q4 9.7% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
78.4%
13.5 pts better
|
81.7%
10.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 95.2% · Q3 92.1% · Q4 86.6% · 4Q avg 91.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
9.9%
0.8 pts worse
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 11.1% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.3% |
80.6%
13.7 pts better
|
79.7%
14.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
21.2%
5.2 pts worse
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 24.4% · Expected 22.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-08 · Fire 2019-08-08
16 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2018-04-10 · Fire 2018-04-10
33 health deficiencies
Top issue: Resident Assessment and Care Planning (8 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-31
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-07-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-07-31
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-15
F · Potential for more than minimal harm
2024-07-31
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 2024-10-15
F · Potential for more than minimal harm
2024-07-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-07-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-07-31
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 2024-10-15
E · Potential for more than minimal harm
2024-07-31
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 2024-10-15
E · Potential for more than minimal harm
2024-07-31
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-07-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-07-31
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-07-31
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-07-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-10-15
E · Potential for more than minimal harm
2024-07-31
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-07-31
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-07-31
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-07-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-07-31
K524 · Services Deficiencies
Fire Safety
Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-07-31
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-10-15
D · Potential for more than minimal harm
2024-07-31
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-10-15
D · Potential for more than minimal harm
2019-08-08
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 2019-09-27
D · Potential for more than minimal harm
2019-08-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-09-27
F · Potential for more than minimal harm
2018-04-10
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-07-20
F · Potential for more than minimal harm
2018-04-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-07-20
F · Potential for more than minimal harm
2018-04-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-07-20
F · Potential for more than minimal harm
2018-04-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-07-20
E · Potential for more than minimal harm
2018-04-10
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2018-07-20
D · Potential for more than minimal harm
2018-04-10
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 2018-07-20
D · Potential for more than minimal harm
2018-04-10
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2018-07-20
D · Potential for more than minimal harm
2018-04-10
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-07-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-06
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-11-27
E · Potential for more than minimal harm
2025-10-06
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 2025-11-27
D · Potential for more than minimal harm
2025-10-06
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 2025-11-27
F · Potential for more than minimal harm
2024-07-31
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 2024-10-08
E · Potential for more than minimal harm
2024-07-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-08
E · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-07-31
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-07-31
F690 · Quality of Life and Care Deficiencies
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-08
D · Potential for more than minimal harm
2024-07-31
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 2024-10-08
D · Potential for more than minimal harm
2024-07-31
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-10-08
E · Potential for more than minimal harm
2023-11-15
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 2023-12-08
E · Potential for more than minimal harm
2023-11-15
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 2023-12-08
E · Potential for more than minimal harm
2023-11-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
D · Potential for more than minimal harm
2023-11-15
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 2023-12-08
C · Minimal harm
2023-11-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-12-08
E · Potential for more than minimal harm
2019-08-08
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 2019-09-12
E · Potential for more than minimal harm
2019-08-08
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 2019-09-12
E · Potential for more than minimal harm
2019-08-08
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-09-12
E · Potential for more than minimal harm
2019-08-08
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 2019-09-12
D · Potential for more than minimal harm
2019-08-08
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 2019-09-12
D · Potential for more than minimal harm
2019-08-08
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 2019-09-12
D · Potential for more than minimal harm
2019-08-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-09-12
D · Potential for more than minimal harm
2019-08-08
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 2019-09-12
D · Potential for more than minimal harm
2019-08-08
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 2019-09-12
D · Potential for more than minimal harm
2019-08-08
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-09-12
D · Potential for more than minimal harm
2019-08-08
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 2019-09-12
D · Potential for more than minimal harm
2019-08-08
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-09-12
D · Potential for more than minimal harm
2019-08-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-09-12
D · Potential for more than minimal harm
2019-08-08
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 2019-09-12
D · Potential for more than minimal harm
2019-08-08
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 2019-09-12
D · Potential for more than minimal harm
2019-08-08
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 2019-09-12
F · Potential for more than minimal harm
2018-04-10
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2018-05-18
E · Potential for more than minimal harm
2018-04-10
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 2018-05-18
E · Potential for more than minimal harm
2018-04-10
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 2018-05-18
E · Potential for more than minimal harm
2018-04-10
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 2018-05-18
E · Potential for more than minimal harm
2018-04-10
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 2018-05-18
D · Potential for more than minimal harm
2018-04-10
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 2018-05-18
D · Potential for more than minimal harm
2018-04-10
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 2018-05-18
D · Potential for more than minimal harm
2018-04-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-05-18
D · Potential for more than minimal harm
2018-04-10
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 2018-05-18
D · Potential for more than minimal harm
2018-04-10
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 2018-05-18
D · Potential for more than minimal harm
2018-04-10
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-05-18
D · Potential for more than minimal harm
2018-04-10
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 2018-05-18
D · Potential for more than minimal harm
2018-04-10
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 2018-05-18
Penalties and ownership
What sits behind the stars
Ownership
115 East Melrose 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
Abramson, Joseph
Operational/Managerial Control · Individual
Accurate Staffing LLC
Operational/Managerial Control · Organization
Brand Sonnenschine Llp
Operational/Managerial Control · Organization
Mirza, Ziad
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
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1-star overall rating with 2-star inspections with abuse icon flag with 32 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Holly Hill Healthcare Center
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2-star overall rating with 1-star inspections with abuse icon flag with 33 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Complete Care At Multi Medical Center LLC
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5-star overall rating with 4-star inspections with 11 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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