Cycle 1
Health 2023-11-20 · Fire 2023-11-20
52 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Baltimore, MD
Carroll Park Healthcare
0-star overall rating with 0-star inspections with Special Focus status with abuse icon flag with $306,550 in total fines with 52 recent health deficiencies with 18 fire-safety deficiencies in the latest cycle
3330 Wilkens Avenue, Baltimore, MD
(410) 525-1544
Overall
0 / 5
CMS overall stars
Health inspections
0 / 5
Survey and complaint cycles
Staffing
0 / 5
RN + nurse staffing
Quality measures
0 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
81
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Engage Healthcare
Operator or chain grouping
Approved since
1972-05-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing
LPN hours / resident day
1.02
Licensed practical nurse staffing
Aide hours / resident day
1.69
Nurse aide staffing
Weekend hours
3.07
Weekend nurse staffing
RN turnover
56%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.2
1.2 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.2% |
91.9%
1.3 pts better
|
93.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 87.0% |
96.6%
9.6 pts worse
|
95.5%
8.5 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
2.3%
0.3 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 41.5% |
21.4%
20.1 pts worse
|
11.4%
30.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 0.3% |
5.7%
5.4 pts better
|
5.4%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
16.1%
5.8 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 9.9% |
15.3%
5.4 pts better
|
16.7%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 38.2% |
26.6%
11.6 pts worse
|
16.3%
21.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
22.9%
1.1 pts better
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
0.7%
0.4 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 33.7% |
25.4%
8.3 pts worse
|
19.8%
13.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.3% |
6.3%
About the same
|
5.1%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.1% |
78.4%
10.3 pts worse
|
81.7%
13.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 43.8% |
80.6%
36.8 pts worse
|
79.7%
35.9 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| 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 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-12-11 · Fire 2019-12-11
50 health deficiencies
Top issue: Quality of Life and Care (12 deficiencies)
15 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Cycle 3
Health 2018-07-19 · Fire 2018-07-19
36 health deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
12 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2023-11-20
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
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 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-11-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-11-20
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-11-20
F · Potential for more than minimal harm
2023-11-20
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-02-14
F · Potential for more than minimal harm
2023-11-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-14
E · Potential for more than minimal harm
2023-11-20
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-20
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-11-20
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 2024-02-14
E · Potential for more than minimal harm
2023-11-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-11-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-20
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-11-20
E · Potential for more than minimal harm
2023-11-20
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 2023-12-15
E · Potential for more than minimal harm
2023-11-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-20
E · Potential for more than minimal harm
2019-12-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-01-16
E · Potential for more than minimal harm
2019-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-01-16
E · Potential for more than minimal harm
2019-12-11
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-01-16
E · Potential for more than minimal harm
2019-12-11
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2020-01-16
D · Potential for more than minimal harm
2019-12-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-01-16
F · Potential for more than minimal harm
2018-07-19
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-10-05
F · Potential for more than minimal harm
2018-07-19
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2018-10-05
F · Potential for more than minimal harm
2018-07-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2018-10-05
F · Potential for more than minimal harm
2018-07-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-10-05
F · Potential for more than minimal harm
2018-07-19
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-10-05
F · Potential for more than minimal harm
2018-07-19
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2018-10-05
F · Potential for more than minimal harm
2018-07-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2018-10-05
E · Potential for more than minimal harm
2018-07-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-10-05
D · Potential for more than minimal harm
2018-07-19
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2018-10-05
D · Potential for more than minimal harm
2018-07-19
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2018-10-05
D · Potential for more than minimal harm
2018-07-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2018-10-31
D · Potential for more than minimal harm
2018-07-19
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2018-10-05
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-14
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-05-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
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 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
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 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F728 · Nursing and Physician Services Deficiencies
Health
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-05-14
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 2025-06-20
K · Immediate jeopardy
2023-11-20
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 2024-05-13
K · Immediate jeopardy
2023-11-20
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-13
J · Immediate jeopardy
2023-11-20
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 2024-01-05
J · Immediate jeopardy
2023-11-20
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 2024-05-13
F · Potential for more than minimal harm
2023-11-20
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 2024-05-13
F · Potential for more than minimal harm
2023-11-20
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 2024-05-13
F · Potential for more than minimal harm
2023-11-20
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-05-13
F · Potential for more than minimal harm
2023-11-20
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-05-13
E · Potential for more than minimal harm
2023-11-20
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-20
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 2024-01-05
E · Potential for more than minimal harm
2023-11-20
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-20
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-20
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-05-13
E · Potential for more than minimal harm
2023-11-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-04-08
E · Potential for more than minimal harm
2023-11-20
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-13
E · Potential for more than minimal harm
2023-11-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-20
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 2024-01-05
E · Potential for more than minimal harm
2023-11-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-05-13
E · Potential for more than minimal harm
2023-11-20
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-11-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
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 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
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 2024-05-13
D · Potential for more than minimal harm
2023-11-20
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 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
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 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2024-04-08
D · Potential for more than minimal harm
2023-11-20
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
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 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-08
D · Potential for more than minimal harm
2023-11-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-11-20
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2024-01-05
J · Immediate jeopardy
2019-12-11
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-02-27
G · Actual harm
2019-12-11
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 2020-02-27
G · Actual harm
2019-12-11
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2020-02-27
G · Actual harm
2019-12-11
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 2020-02-27
F · Potential for more than minimal harm
2019-12-11
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2019-12-11
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 2020-02-27
D · Potential for more than minimal harm
2019-12-11
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 2020-02-27
D · Potential for more than minimal harm
2019-12-11
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 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
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 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F642 · Resident Assessment and Care Planning Deficiencies
Health
Ensure a qualified health professional conducts resident assessments.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
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 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
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 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
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 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2020-02-27
D · Potential for more than minimal harm
2019-12-11
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 2020-02-27
B · Minimal harm
2019-12-11
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 2020-02-27
E · Potential for more than minimal harm
2018-07-19
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 2018-08-31
E · Potential for more than minimal harm
2018-07-19
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2018-08-31
E · Potential for more than minimal harm
2018-07-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2018-08-31
E · Potential for more than minimal harm
2018-07-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-08-31
E · Potential for more than minimal harm
2018-07-19
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 2018-08-31
E · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
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 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-07-19
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2018-08-31
Penalties and ownership
What sits behind the stars
$306,550
2023-11-20
Fine
Fine · fine $306,550
Fine
$0
2023-11-20
Payment Denial
Payment Denial · denial start 2024-02-20 · 83 days
83 day denial
Ownership
Gwynnfalls Md Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Lighten, Jake
5% Or Greater Indirect Ownership Interest · Individual
Paneth, Jack
5% Or Greater Indirect Ownership Interest · Individual
Kuritsky, Yechiel
W-2 Managing Employee · Individual
Lighten, Jake
Operational/Managerial Control · Individual
Nearby options
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#3
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2-star overall rating with 3-star inspections with 20 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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