Cycle 1
Health 2025-08-27 · Fire 2025-08-27
17 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Catonsville, MD
Autumn Lake Healthcare At Summit Park
3-star overall rating with 2-star inspections with $49,221 in total fines with 17 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1502 Frederick Road, Catonsville, MD
(410) 747-3287
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
143
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Autumn Lake Healthcare
Operator or chain grouping
Approved since
1999-12-21
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
0.95
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.81
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.60
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.15
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.64
CMS adjusted RN staffing hours
Adjusted total hours
3.37
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
48%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,288
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
17.39
Composite VBP score used to determine payment impact.
Payment multiplier
0.9818
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.59
Baseline 22.66% · Performance 20.92% · Measure score 2.59 · Achievement 1.10 · Improvement 2.59
Healthcare-associated infections
0
Baseline 8.85% · Performance 8.99% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.25
Performance 54.46% · Measure score 2.25 · Achievement 2.25 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.11
Baseline 3.63 hours · Performance 3.68 hours · Measure score 2.11 · Achievement 2.11 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.97% |
10.72%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 133 · Observed rate 12.03% · Lower 95% interval 7.48% |
| Discharge to community | 51.21% |
50.57%
0.6 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 41.22% · Lower 95% interval 43.01% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 100 · Denominator 100 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 100 |
| Discharge self-care score | 39.13% |
53.69%
14.6 pts worse
|
Numerator 27 · Denominator 69 |
| Discharge mobility score | 57.97% |
50.94%
7 pts better
|
Numerator 40 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 1% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 100 · Adjusted rate 0.61% |
| Healthcare-associated infections requiring hospitalization | 8.99% |
7.12%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 12.5% · Lower 95% interval 5.61% |
| Staff COVID-19 vaccination coverage | 52.25% |
8.2%
44 pts better
|
Numerator 58 · Denominator 111 |
| Staff flu vaccination coverage | 55.05% |
42%
13 pts better
|
Numerator 60 · Denominator 109 |
| Discharge function score | 52.17% |
56.45%
4.3 pts worse
|
Numerator 36 · Denominator 69 |
| Transfer of health information to provider | 96.3% |
95.95%
0.3 pts better
|
Numerator 26 · Denominator 27 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 43 · Denominator 43 |
| Resident COVID-19 vaccinations up to date | 34.69% |
25.2%
9.5 pts better
|
Numerator 17 · Denominator 49 |
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 2.2 · Expected 3.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.4 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.8% |
91.9%
6.9 pts better
|
93.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.0% · Q3 99.0% · Q4 98.0% · 4Q avg 98.8% |
| 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 | 1.0% |
2.3%
1.3 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.0% · Q3 1.0% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.7% |
21.4%
8.7 pts better
|
11.4%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.2% · Q2 21.3% · Q3 8.4% · Q4 11.6% · 4Q avg 12.7% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.7%
0.4 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 6.4% · Q3 3.3% · Q4 4.3% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 37.8% |
16.1%
21.7 pts worse
|
19.6%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 25.5% · Q3 60.6% · Q4 58.5% · 4Q avg 37.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.9% |
15.3%
4.4 pts better
|
16.7%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 8.7% · Q3 8.5% · Q4 10.0% · 4Q avg 10.9% · 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 | 18.2% |
26.6%
8.4 pts better
|
16.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.7% · Q2 21.6% · Q3 12.7% · Q4 4.3% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.0% |
22.9%
7.9 pts better
|
14.9%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 19.5% · Q3 9.2% · Q4 12.8% · 4Q avg 15.0% · 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 0.0% · Q2 0.5% · Q3 0.0% · Q4 1.9% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.9% |
25.4%
1.5 pts worse
|
19.8%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 31.7% · Q3 31.1% · Q4 18.8% · 4Q avg 26.9% |
| Percentage of long-stay residents with pressure ulcers | 10.0% |
6.3%
3.7 pts worse
|
5.1%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 10.1% · Q3 11.0% · Q4 8.4% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
78.4%
14 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 89.8% · Q2 89.4% · Q3 93.3% · Q4 96.8% · 4Q avg 92.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.4% |
9.9%
3.5 pts better
|
12.0%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.4% · Observed 6.5% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
80.6%
7.4 pts better
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.2% |
21.2%
6 pts better
|
23.9%
8.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 15.6% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-22 · Fire 2023-12-22
32 health deficiencies
Top issue: Resident Rights (7 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2019-03-21 · Fire 2019-03-21
31 health deficiencies
Top issue: Resident Rights (10 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-08-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2026-02-11
F · Potential for more than minimal harm
2025-08-27
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-11
F · Potential for more than minimal harm
2025-08-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2026-02-11
E · Potential for more than minimal harm
2025-08-27
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 2026-02-11
E · Potential for more than minimal harm
2025-08-27
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2026-02-11
E · Potential for more than minimal harm
2025-08-27
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2026-02-11
E · Potential for more than minimal harm
2025-08-27
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2026-02-11
E · Potential for more than minimal harm
2025-08-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2026-02-11
D · Potential for more than minimal harm
2025-08-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-02-11
F · Potential for more than minimal harm
2023-12-22
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-03-05
F · Potential for more than minimal harm
2023-12-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-05
F · Potential for more than minimal harm
2023-12-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-12-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-22
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 2024-03-05
E · Potential for more than minimal harm
2023-12-22
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-02-01
E · Potential for more than minimal harm
2023-12-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-22
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-22
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 2024-02-01
D · Potential for more than minimal harm
2023-12-22
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-22
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-01
D · Potential for more than minimal harm
2023-12-22
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-03-05
D · Potential for more than minimal harm
2019-03-21
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-03-21
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-03-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-06-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-27
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-27
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 2025-10-10
E · Potential for more than minimal harm
2025-08-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-10-10
E · Potential for more than minimal harm
2025-08-27
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
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 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
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 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-10-10
D · Potential for more than minimal harm
2025-08-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-10
G · Actual harm
2023-12-22
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-02-06
F · Potential for more than minimal harm
2023-12-22
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 2024-02-06
F · Potential for more than minimal harm
2023-12-22
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 2024-02-06
F · Potential for more than minimal harm
2023-12-22
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 2024-02-06
E · Potential for more than minimal harm
2023-12-22
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-02-06
E · Potential for more than minimal harm
2023-12-22
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
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 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-12-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-06
C · Minimal harm
2023-12-22
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-02-06
D · Potential for more than minimal harm
2023-11-13
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 2023-12-20
D · Potential for more than minimal harm
2023-11-13
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2023-12-20
J · Immediate jeopardy
2019-03-21
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 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2019-07-30
D · Potential for more than minimal harm
2019-03-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-07-30
D · Potential for more than minimal harm
2019-03-21
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 2019-07-30
D · Potential for more than minimal harm
2019-03-21
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-07-30
D · Potential for more than minimal harm
2019-03-21
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-07-30
D · Potential for more than minimal harm
2019-03-21
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 2019-07-30
D · Potential for more than minimal harm
2019-03-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F776 · Administration Deficiencies
Health
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
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 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2019-05-21
D · Potential for more than minimal harm
2019-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-05-21
Penalties and ownership
What sits behind the stars
$49,221
2023-11-13
Fine
Fine · fine $49,221
Fine
Ownership
1502 Frederick 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
Langer, Yaakov
Operational/Managerial Control · Individual
Schwartz, Mark
Operational/Managerial Control · Individual
Schwartz, Mark
Corporate Officer · Individual
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