Cycle 1
Health 2025-07-25 · Fire 2025-07-25
13 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Baltimore, MD
Autumn Lake Healthcare At Parkville
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
8710 Emge Road, Baltimore, MD
(410) 661-5955
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
135
Certified beds
Average residents
120
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1980-11-19
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
0.65
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.40
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.09
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.50
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
0.61
CMS adjusted RN staffing hours
Adjusted total hours
3.10
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
60%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,405
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.32
Baseline 21.48% · Performance 19.43% · Measure score 4.32 · Achievement 4.32 · Improvement 4.1
Healthcare-associated infections
2.02
Baseline 7.74% · Performance 7.23% · Measure score 2.02 · Achievement 2.02 · Improvement 1.34
Total nurse turnover
2.04
Performance 55.34% · Measure score 2.04 · Achievement 2.04 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.37
Baseline 2.21 hours · Performance 3.24 hours · Measure score 2.37 · Achievement 0.56 · Improvement 2.37
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.57% |
10.72%
2.8 pts worse
|
No Different than the National Rate · Eligible stays 171 · Observed rate 23.98% · Lower 95% interval 10.62% |
| Discharge to community | 44.48% |
50.57%
6.1 pts worse
|
No Different than the National Rate · Eligible stays 179 · Observed rate 28.49% · Lower 95% interval 35.16% |
| Medicare spending per beneficiary | 1.43 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 147 · Denominator 154 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 154 |
| Discharge self-care score | 38.46% |
53.69%
15.2 pts worse
|
Numerator 30 · Denominator 78 |
| Discharge mobility score | 41.03% |
50.94%
9.9 pts worse
|
Numerator 32 · Denominator 78 |
| Pressure ulcers or injuries, new or worsened | 3.9% |
2.29%
1.6 pts worse
|
Numerator 6 · Denominator 154 · Adjusted rate 2.75% |
| Healthcare-associated infections requiring hospitalization | 7.23% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 134 · Observed rate 9.7% · Lower 95% interval 4.84% |
| Staff COVID-19 vaccination coverage | 7.37% |
8.2%
0.8 pts worse
|
Numerator 7 · Denominator 95 |
| Staff flu vaccination coverage | 79.09% |
42%
37.1 pts better
|
Numerator 87 · Denominator 110 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 39 · Denominator 78 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 84 · Denominator 84 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 38 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 2.44% |
25.2%
22.8 pts worse
|
Numerator 2 · Denominator 82 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.5 · Expected 2.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.6 · Expected 1.9 · 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 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
96.6%
2.5 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
2.3%
0.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.0% · Q3 2.0% · Q4 1.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.0% |
21.4%
8.4 pts better
|
11.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 0.0% · Q3 8.8% · Q4 40.6% · 4Q avg 13.0% |
| 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 2.0% · Q2 7.3% · Q3 4.4% · Q4 3.2% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.9% |
16.1%
11.8 pts worse
|
19.6%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 22.7% · Q3 23.3% · Q4 43.8% · 4Q avg 27.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 28.7% |
15.3%
13.4 pts worse
|
16.7%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 30.3% · Q3 28.4% · Q4 29.5% · 4Q avg 28.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 40.3% |
26.6%
13.7 pts worse
|
16.3%
24 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.4% · Q2 20.1% · Q3 46.8% · Q4 29.9% · 4Q avg 40.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 32.7% |
22.9%
9.8 pts worse
|
14.9%
17.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 36.6% · Q2 27.5% · Q3 30.1% · Q4 36.5% · 4Q avg 32.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.7%
0.1 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.7% · Q3 0.8% · Q4 0.0% · 4Q avg 0.6% · 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 1.0% · Q2 0.0% · Q3 2.0% · 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 | 29.2% |
25.4%
3.8 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.3% · Q2 33.9% · Q3 26.8% · Q4 31.8% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
6.3%
3.4 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 4.7% · Q3 2.4% · Q4 1.8% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
78.4%
9.5 pts better
|
81.7%
6.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 66.0% · Q2 86.2% · Q3 98.7% · Q4 99.3% · 4Q avg 87.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
9.9%
2.3 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 9.6% · Expected 14.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.3%
0.3 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 0.0% · Q3 1.0% · Q4 1.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 78.5% |
80.6%
2.1 pts worse
|
79.7%
1.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 78.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
21.2%
2 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 26.5% · Expected 32.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2022-11-17 · Fire 2022-11-17
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
22 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Cycle 3
Health 2018-12-11 · Fire 2018-12-11
12 health deficiencies
Top issue: Resident Rights (3 deficiencies)
10 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-07-25
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-11-25
F · Potential for more than minimal harm
2025-07-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-11-25
F · Potential for more than minimal harm
2025-07-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-11-25
F · Potential for more than minimal harm
2025-07-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-07-25
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-07-25
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-07-25
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-07-25
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 2025-11-25
E · Potential for more than minimal harm
2025-07-25
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-07-25
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-07-25
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-07-25
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-11-25
E · Potential for more than minimal harm
2025-07-25
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 2025-11-25
E · Potential for more than minimal harm
2025-07-25
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-07-25
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-07-25
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-07-25
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-07-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-11-25
F · Potential for more than minimal harm
2022-11-17
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-28
F · Potential for more than minimal harm
2022-11-17
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-11-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-11-17
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-11-17
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-11-17
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-01-23
F · Potential for more than minimal harm
2022-11-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-28
E · Potential for more than minimal harm
2022-11-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-11-17
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 2023-01-23
E · Potential for more than minimal harm
2022-11-17
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 2023-01-23
E · Potential for more than minimal harm
2022-11-17
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-11-17
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 2023-01-23
E · Potential for more than minimal harm
2022-11-17
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-11-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-11-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-01-23
E · Potential for more than minimal harm
2022-11-17
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-17
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-17
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-17
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 2023-01-23
D · Potential for more than minimal harm
2022-11-17
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-17
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-01-23
D · Potential for more than minimal harm
2022-11-17
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-01-23
F · Potential for more than minimal harm
2018-12-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-03-15
F · Potential for more than minimal harm
2018-12-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-03-15
E · Potential for more than minimal harm
2018-12-11
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-03-15
D · Potential for more than minimal harm
2018-12-11
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2019-03-15
D · Potential for more than minimal harm
2018-12-11
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 2019-03-15
D · Potential for more than minimal harm
2018-12-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-03-15
D · Potential for more than minimal harm
2018-12-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2019-03-15
D · Potential for more than minimal harm
2018-12-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-03-15
D · Potential for more than minimal harm
2018-12-11
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 2019-03-15
D · Potential for more than minimal harm
2018-12-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-03-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-25
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-25
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 2025-09-05
D · Potential for more than minimal harm
2025-07-25
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 2025-09-05
D · Potential for more than minimal harm
2025-07-25
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 2025-09-05
D · Potential for more than minimal harm
2025-07-25
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-25
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-25
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-07-25
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-05
D · Potential for more than minimal harm
2025-04-14
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 2025-05-25
D · Potential for more than minimal harm
2025-04-14
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 2025-05-25
D · Potential for more than minimal harm
2025-04-14
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-25
D · Potential for more than minimal harm
2025-04-14
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 2025-05-25
J · Immediate jeopardy
2022-11-17
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2020-06-20
E · Potential for more than minimal harm
2022-11-17
F572 · Resident Rights Deficiencies
Health
Give residents a notice of rights, rules, services and charges.
Corrected 2023-02-01
E · Potential for more than minimal harm
2022-11-17
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-02-01
E · Potential for more than minimal harm
2022-11-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-02-01
D · Potential for more than minimal harm
2022-11-17
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 2023-02-01
D · Potential for more than minimal harm
2022-11-17
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 2023-02-01
D · Potential for more than minimal harm
2022-11-17
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 2023-02-01
D · Potential for more than minimal harm
2022-11-17
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 2023-02-01
D · Potential for more than minimal harm
2022-11-17
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-02-01
D · Potential for more than minimal harm
2022-11-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-02-01
D · Potential for more than minimal harm
2022-11-17
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-02-16
D · Potential for more than minimal harm
2022-11-17
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2023-02-01
E · Potential for more than minimal harm
2018-12-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2019-02-18
E · Potential for more than minimal harm
2018-12-11
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 2019-02-18
D · Potential for more than minimal harm
2018-12-11
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 2019-02-18
D · Potential for more than minimal harm
2018-12-11
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 2019-02-18
D · Potential for more than minimal harm
2018-12-11
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 2019-02-18
D · Potential for more than minimal harm
2018-12-11
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 2019-02-18
D · Potential for more than minimal harm
2018-12-11
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-02-18
D · Potential for more than minimal harm
2018-12-11
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 2019-02-18
D · Potential for more than minimal harm
2018-12-11
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2019-02-18
D · Potential for more than minimal harm
2018-12-11
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 2019-02-18
D · Potential for more than minimal harm
2018-12-11
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 2019-02-18
D · Potential for more than minimal harm
2018-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-02-18
Penalties and ownership
What sits behind the stars
Ownership
Bharaj, Narender
Operational/Managerial Control · Individual
Nozea, Valerie
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
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2-star overall rating with 2-star inspections with 24 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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#3
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