Cycle 1
Health 2023-02-03 · Fire 2023-02-03
35 health deficiencies
Top issue: Resident Assessment and Care Planning (8 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Annapolis, MD
Autumn Lake Healthcare At Spa Creek
2-star overall rating with 1-star inspections with 35 recent health deficiencies with 16 fire-safety deficiencies in the latest cycle
35 Milkshake Lane, Annapolis, MD
(410) 269-5100
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
114
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1994-01-06
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
0.53
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.78
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.96
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.42
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.39
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.15
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.46
CMS adjusted RN staffing hours
Adjusted total hours
3.33
CMS adjusted total nurse staffing hours
Case-mix index
1.56
Higher values indicate more complex resident acuity
RN turnover
55%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
55%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,717
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.38
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.68
Baseline 20.68% · Performance 20.19% · Measure score 2.68 · Achievement 2.68 · Improvement 0.85
Healthcare-associated infections
1.76
Baseline 7.11% · Performance 7.31% · Measure score 1.76 · Achievement 1.76 · Improvement 0
Total nurse turnover
2.16
Baseline 66.67% · Performance 55.56% · Measure score 2.16 · Achievement 1.99 · Improvement 2.16
Adjusted total nurse staffing
1.15
Baseline 3.13 hours · Performance 3.41 hours · Measure score 1.15 · Achievement 1.15 · Improvement 0.53
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 16.06% |
10.72%
5.3 pts worse
|
Worse than the National Rate · Eligible stays 658 · Observed rate 16.72% · Lower 95% interval 13.13% |
| Discharge to community | 62.32% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 650 · Observed rate 57.54% · Lower 95% interval 58.86% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 382 · Denominator 382 |
| Falls with major injury | 0.52% |
0.77%
0.2 pts better
|
Numerator 2 · Denominator 382 |
| Discharge self-care score | 56.15% |
53.69%
2.5 pts better
|
Numerator 146 · Denominator 260 |
| Discharge mobility score | 49.62% |
50.94%
1.3 pts worse
|
Numerator 129 · Denominator 260 |
| Pressure ulcers or injuries, new or worsened | 2.36% |
2.29%
0.1 pts worse
|
Numerator 9 · Denominator 382 · Adjusted rate 1.91% |
| Healthcare-associated infections requiring hospitalization | 7.31% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 389 · Observed rate 6.68% · Lower 95% interval 5.35% |
| Staff COVID-19 vaccination coverage | 14.14% |
8.2%
5.9 pts better
|
Numerator 14 · Denominator 99 |
| Staff flu vaccination coverage | 65.71% |
42%
23.7 pts better
|
Numerator 69 · Denominator 105 |
| Discharge function score | 60.77% |
56.45%
4.3 pts better
|
Numerator 158 · Denominator 260 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 84 · Denominator 84 |
| Transfer of health information to patient | 95.67% |
96.28%
0.6 pts worse
|
Numerator 265 · Denominator 277 |
| Resident COVID-19 vaccinations up to date | 38.38% |
25.2%
13.2 pts better
|
Numerator 76 · Denominator 198 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.6 · Observed 0.5 · Expected 1.7 · 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 0.5 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.9%
7.4 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.2% · 4Q avg 99.3% |
| 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 | 1.0% |
2.3%
1.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 2.8% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.1% |
21.4%
5.3 pts better
|
11.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 21.6% · Q3 10.6% · Q4 11.9% · 4Q avg 16.1% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
5.7%
3.3 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 3.2% · Q3 0.0% · Q4 1.6% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.2% |
16.1%
6.9 pts better
|
19.6%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 9.5% · Q3 9.4% · Q4 9.7% · 4Q avg 9.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.5% |
15.3%
12.8 pts better
|
16.7%
14.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 2.0% · Q3 2.0% · Q4 1.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.1% |
26.6%
1.5 pts better
|
16.3%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.2% |
22.9%
2.7 pts better
|
14.9%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 15.5% · Q3 24.1% · Q4 19.6% · 4Q avg 20.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.7%
0.7 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.9% · Q3 1.1% · Q4 0.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.5%
0.2 pts worse
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.5% |
25.4%
0.9 pts better
|
19.8%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 23.8% · Q3 23.5% · Q4 30.5% · 4Q avg 24.5% |
| Percentage of long-stay residents with pressure ulcers | 3.9% |
6.3%
2.4 pts better
|
5.1%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.9% · Q3 2.4% · Q4 3.9% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.4% |
78.4%
19 pts better
|
81.7%
15.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.4% · Q2 96.0% · Q3 98.9% · Q4 99.7% · 4Q avg 97.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
9.9%
0.8 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.9% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.3%
1.1 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
80.6%
11.4 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.7% |
21.2%
1.5 pts worse
|
23.9%
1.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.7% · Observed 20.9% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2018-11-05 · Fire 2018-11-05
21 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2017-07-13 · Fire 2017-07-13
6 health deficiencies
Top issue: Administration (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2023-02-03
K232 · Egress Deficiencies
Fire Safety
Have corridors or aisles that are unobstructed and are at least 8 feet in width.
Corrected 2023-05-02
E · Potential for more than minimal harm
2023-02-03
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 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
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 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-02-03
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
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 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2023-05-02
D · Potential for more than minimal harm
2023-02-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-06-02
D · Potential for more than minimal harm
2023-02-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-05-02
E · Potential for more than minimal harm
2017-07-13
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-07-13
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 2017-08-31
D · Potential for more than minimal harm
2017-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-07-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-07-13
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-07-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-07-13
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2017-08-31
D · Potential for more than minimal harm
2017-07-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2017-08-31
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-06
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-10-04
E · Potential for more than minimal harm
2025-08-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-04
E · Potential for more than minimal harm
2025-06-04
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 2025-07-10
E · Potential for more than minimal harm
2025-06-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-07-10
E · Potential for more than minimal harm
2025-06-04
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-04
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 2025-07-10
D · Potential for more than minimal harm
2025-06-04
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 2025-07-10
D · Potential for more than minimal harm
2025-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-07-10
D · Potential for more than minimal harm
2025-06-04
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 2025-07-10
D · Potential for more than minimal harm
2025-06-04
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 2025-07-10
D · Potential for more than minimal harm
2025-06-04
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 2025-07-10
E · Potential for more than minimal harm
2023-02-03
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 2023-04-05
E · Potential for more than minimal harm
2023-02-03
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-05
E · Potential for more than minimal harm
2023-02-03
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 2023-04-05
E · Potential for more than minimal harm
2023-02-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
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 2023-04-05
D · Potential for more than minimal harm
2023-02-03
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 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F603 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
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 2023-04-05
D · Potential for more than minimal harm
2023-02-03
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 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
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 2023-04-05
D · Potential for more than minimal harm
2023-02-03
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 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-04-05
D · Potential for more than minimal harm
2023-02-03
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 2023-04-05
D · Potential for more than minimal harm
2023-02-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-04-05
K · Immediate jeopardy
2018-11-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-12-29
E · Potential for more than minimal harm
2018-11-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-12-29
E · Potential for more than minimal harm
2018-11-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-12-29
E · Potential for more than minimal harm
2018-11-05
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2018-12-29
E · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-05
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-12-29
D · Potential for more than minimal harm
2018-11-05
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 2018-12-29
D · Potential for more than minimal harm
2018-11-05
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2018-12-29
D · Potential for more than minimal harm
2017-07-13
F166 · Resident Rights Deficiencies
Health
Try to resolve each resident's complaints quickly.
Corrected 2017-08-27
D · Potential for more than minimal harm
2017-07-13
F274 · Resident Assessment and Care Planning Deficiencies
Health
Review or revise the resident's care plan after any major change in physical or mental health.
Corrected 2017-08-27
D · Potential for more than minimal harm
2017-07-13
F315 · Quality of Life and Care Deficiencies
Health
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
Corrected 2017-08-27
D · Potential for more than minimal harm
2017-07-13
F371 · Nutrition and Dietary Deficiencies
Health
Store, cook, and serve food in a safe and clean way.
Corrected 2017-08-27
D · Potential for more than minimal harm
2017-07-13
F431 · Pharmacy Service Deficiencies
Health
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
Corrected 2017-08-27
D · Potential for more than minimal harm
2017-07-13
F514 · Administration Deficiencies
Health
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Corrected 2017-08-27
Penalties and ownership
What sits behind the stars
Ownership
35 Milkshake 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
Mcinerney, Ellen
Operational/Managerial Control · Individual
Neel, Elizabeth
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
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