Cycle 1
Health 2025-04-30 · Fire 2025-04-30
16 health deficiencies
Top issue: Environmental (3 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Baltimore, MD
Autumn Lake Healthcare At Overlea
1-star overall rating with 2-star inspections with 16 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
6116 Belair Road, Baltimore, MD
(410) 426-1424
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
160
Certified beds
Average residents
139
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1989-11-01
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
0.46
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.94
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.28
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.08
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
39%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,566
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.75
Composite VBP score used to determine payment impact.
Payment multiplier
0.9968
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
7.81
Baseline 19.89% · Performance 17.81% · Measure score 7.81 · Achievement 7.81 · Improvement 6.77
Healthcare-associated infections
1.19
Baseline 8.37% · Performance 7.80% · Measure score 1.19 · Achievement 0 · Improvement 1.19
Total nurse turnover
7.49
Performance 33.06% · Measure score 7.49 · Achievement 7.49 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
1
Baseline 3.94 hours · Performance 3.36 hours · Measure score 1 · Achievement 1 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.59% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 151 · Observed rate 15.89% · Lower 95% interval 9.35% |
| Discharge to community | 48.04% |
50.57%
2.5 pts worse
|
No Different than the National Rate · Eligible stays 105 · Observed rate 36.19% · Lower 95% interval 38.91% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 99.28% |
95.27%
4 pts better
|
Numerator 137 · Denominator 138 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 138 |
| Discharge self-care score | 50.51% |
53.69%
3.2 pts worse
|
Numerator 50 · Denominator 99 |
| Discharge mobility score | 44.44% |
50.94%
6.5 pts worse
|
Numerator 44 · Denominator 99 |
| Pressure ulcers or injuries, new or worsened | 4.35% |
2.29%
2.1 pts worse
|
Numerator 6 · Denominator 138 · Adjusted rate 3.62% |
| Healthcare-associated infections requiring hospitalization | 7.8% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 10% · Lower 95% interval 4.58% |
| Staff COVID-19 vaccination coverage | 1.25% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 160 |
| Staff flu vaccination coverage | 74.09% |
42%
32.1 pts better
|
Numerator 163 · Denominator 220 |
| Discharge function score | 51.52% |
56.45%
4.9 pts worse
|
Numerator 51 · Denominator 99 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 30 · Denominator 30 |
| Transfer of health information to patient | 84.78% |
96.28%
11.5 pts worse
|
Numerator 39 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 20.29% |
25.2%
4.9 pts worse
|
Numerator 14 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.3
About the same
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.5 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.9%
7.9 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.2% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
2.3%
0.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.1% · Q4 3.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 52.7% |
21.4%
31.3 pts worse
|
11.4%
41.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 49.6% · Q3 78.3% · Q4 71.9% · 4Q avg 52.7% |
| Percentage of long-stay residents who lose too much weight | 9.7% |
5.7%
4 pts worse
|
5.4%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 15.1% · Q3 7.3% · Q4 8.9% · 4Q avg 9.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
16.1%
4.4 pts worse
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.5% · Q2 16.7% · Q3 12.1% · Q4 38.7% · 4Q avg 20.5% |
| 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 | 19.4% |
26.6%
7.2 pts better
|
16.3%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 11.9% · Q3 24.4% · Q4 18.0% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
22.9%
1.2 pts better
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.2% · Q2 25.9% · Q3 16.8% · Q4 15.9% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.7%
0.1 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
1.5%
0.5 pts worse
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 3.0% · Q3 0.8% · Q4 0.8% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
25.4%
0.3 pts better
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 22.5% · Q3 22.3% · Q4 30.2% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.3%
0.3 pts better
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 9.3% · Q3 4.5% · Q4 4.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
78.4%
19.8 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 96.2% · Q3 98.7% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.0% |
9.9%
3.9 pts better
|
12.0%
6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.0% · Observed 6.3% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.2% |
1.3%
4.9 pts worse
|
1.6%
4.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 6.1% · Q3 7.7% · Q4 6.8% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.6% |
80.6%
11 pts better
|
79.7%
11.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
21.2%
4.6 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 15.8% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-08-04 · Fire 2021-08-04
19 health deficiencies
Top issue: Resident Assessment and Care Planning (6 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2018-08-31 · Fire 2018-08-31
28 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-04
F · Potential for more than minimal harm
2025-04-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-06-04
F · Potential for more than minimal harm
2025-04-30
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-06-04
F · Potential for more than minimal harm
2025-04-30
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-06-04
F · Potential for more than minimal harm
2025-04-30
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 2025-06-04
F · Potential for more than minimal harm
2025-04-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-04-30
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-04-30
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-06-04
D · Potential for more than minimal harm
2025-04-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-06-04
F · Potential for more than minimal harm
2021-08-04
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2021-08-27
F · Potential for more than minimal harm
2021-08-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-08-27
E · Potential for more than minimal harm
2021-08-04
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 2021-08-27
E · Potential for more than minimal harm
2021-08-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-08-27
E · Potential for more than minimal harm
2021-08-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-08-27
E · Potential for more than minimal harm
2021-08-04
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2021-08-27
E · Potential for more than minimal harm
2021-08-04
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-04
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-04
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-04
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 2021-08-27
D · Potential for more than minimal harm
2021-08-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-04
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-04
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-08-27
D · Potential for more than minimal harm
2021-08-04
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 2021-08-27
F · Potential for more than minimal harm
2018-08-31
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-12-30
F · Potential for more than minimal harm
2018-08-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-12-30
F · Potential for more than minimal harm
2018-08-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-12-30
F · Potential for more than minimal harm
2018-08-31
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-12-30
E · Potential for more than minimal harm
2018-08-31
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2018-12-30
E · Potential for more than minimal harm
2018-08-31
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 2018-12-30
E · Potential for more than minimal harm
2018-08-31
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2018-12-30
D · Potential for more than minimal harm
2018-08-31
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2018-12-30
D · Potential for more than minimal harm
2018-08-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-12-30
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-10-22
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-10
D · Potential for more than minimal harm
2025-10-22
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 2025-11-10
D · Potential for more than minimal harm
2025-10-22
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 2025-11-10
F · Potential for more than minimal harm
2025-04-30
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-04-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-30
F · Potential for more than minimal harm
2025-04-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-04-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-04-30
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-04-30
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 2025-06-20
E · Potential for more than minimal harm
2025-04-30
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 2025-06-20
D · Potential for more than minimal harm
2025-04-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-04-30
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-04-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-04-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-04-30
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-02-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-24
E · Potential for more than minimal harm
2025-02-20
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 2025-03-24
D · Potential for more than minimal harm
2025-02-20
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 2025-03-24
D · Potential for more than minimal harm
2025-02-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-20
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 2025-03-24
D · Potential for more than minimal harm
2025-02-20
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 2025-03-24
D · Potential for more than minimal harm
2025-02-20
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 2025-03-24
D · Potential for more than minimal harm
2025-02-20
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-24
D · Potential for more than minimal harm
2025-02-20
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 2025-03-24
E · Potential for more than minimal harm
2021-08-04
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-09-17
E · Potential for more than minimal harm
2021-08-04
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-04
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2021-09-17
D · Potential for more than minimal harm
2021-08-04
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 2021-09-17
D · Potential for more than minimal harm
2021-08-04
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 2021-09-17
D · Potential for more than minimal harm
2021-08-04
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 2021-09-17
D · Potential for more than minimal harm
2021-08-04
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 2021-09-17
D · Potential for more than minimal harm
2021-08-04
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2021-09-17
E · Potential for more than minimal harm
2018-08-31
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 2018-11-05
E · Potential for more than minimal harm
2018-08-31
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-11-05
E · Potential for more than minimal harm
2018-08-31
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F675 · Quality of Life and Care Deficiencies
Health
Honor each resident's preferences, choices, values and beliefs.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
D · Potential for more than minimal harm
2018-08-31
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 2018-11-05
Penalties and ownership
What sits behind the stars
Ownership
6116 Belair Road Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
A&R Stern Family Md7 LLC
5% Or Greater Indirect Ownership Interest · Organization
Baskaran, Deepak
Operational/Managerial Control · Individual
Guttman, Moshe
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
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