25 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Lexington Park, MD
3-star overall rating with 3-star inspections with $47,254 in total fines with 25 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
21412 Great Mills Road, Lexington Park, MD
(301) 863-7244
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
125
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1982-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
RN hours / resident day
0.58
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
47%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
10,865
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.84
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
0
Baseline 21.73% · Performance 21.76% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.88
Baseline 7.01% · Performance 6.98% · Measure score 2.88 · Achievement 2.88 · Improvement 0
Total nurse turnover
3.09
Baseline 55.10% · Performance 51.04% · Measure score 3.09 · Achievement 3.09 · Improvement 0.84
Adjusted total nurse staffing
1.57
Baseline 3.34 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0.26
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.64% |
10.72%
2.9 pts worse
|
Worse than the National Rate · Eligible stays 256 · Observed rate 17.97% · Lower 95% interval 10.89% |
| Discharge to community | 55.08% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 224 · Observed rate 46.43% · Lower 95% interval 48.93% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 96.99% |
95.27%
1.7 pts better
|
Numerator 129 · Denominator 133 |
| Falls with major injury | 1.5% |
0.77%
0.7 pts worse
|
Numerator 2 · Denominator 133 |
| Discharge self-care score | 35.44% |
53.69%
18.2 pts worse
|
Numerator 28 · Denominator 79 |
| Discharge mobility score | 43.04% |
50.94%
7.9 pts worse
|
Numerator 34 · Denominator 79 |
| Pressure ulcers or injuries, new or worsened | 6.77% |
2.29%
4.5 pts worse
|
Numerator 9 · Denominator 133 · Adjusted rate 6.15% |
| Healthcare-associated infections requiring hospitalization | 6.97% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 150 · Observed rate 8% · Lower 95% interval 4.43% |
| Staff COVID-19 vaccination coverage | 1.87% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 107 |
| Staff flu vaccination coverage | 92.92% |
42%
50.9 pts better
|
Numerator 105 · Denominator 113 |
| Discharge function score | 45.57% |
56.45%
10.9 pts worse
|
Numerator 36 · Denominator 79 |
| Transfer of health information to provider | 90.2% |
95.95%
5.8 pts worse
|
Numerator 46 · Denominator 51 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 53 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 63.27% |
25.2%
38.1 pts better
|
Numerator 31 · Denominator 49 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.3
0.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
1.2
1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · 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 98.7% · Q2 98.8% · Q3 98.8% · Q4 98.8% · 4Q avg 98.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
2.3%
2 pts worse
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 4.8% · Q4 6.0% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 18.6% |
21.4%
2.8 pts better
|
11.4%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 21.3% · Q3 22.4% · Q4 14.3% · 4Q avg 18.6% |
| Percentage of long-stay residents who lose too much weight | 8.7% |
5.7%
3 pts worse
|
5.4%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.4% · Q3 8.9% · Q4 8.6% · 4Q avg 8.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
16.1%
0.1 pts better
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 16.5% · Q3 17.1% · Q4 14.5% · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.6% |
15.3%
2.7 pts better
|
16.7%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 15.3% · Q3 9.7% · Q4 11.1% · 4Q avg 12.6% · 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 | 30.7% |
26.6%
4.1 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.2% |
22.9%
6.7 pts better
|
14.9%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 20.0% · Q3 18.2% · Q4 12.7% · 4Q avg 16.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.7%
0.4 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.2% · Q3 0.8% · Q4 0.6% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.8% |
1.5%
1.3 pts worse
|
1.7%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 0.0% · Q4 6.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
25.4%
10 pts better
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 18.5% · Q3 20.0% · Q4 11.4% · 4Q avg 15.4% |
| Percentage of long-stay residents with pressure ulcers | 11.6% |
6.3%
5.3 pts worse
|
5.1%
6.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 13.7% · Q3 14.2% · Q4 9.1% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.9% |
78.4%
13.5 pts better
|
81.7%
10.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 94.4% · Q3 88.2% · Q4 88.7% · 4Q avg 91.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.7% |
9.9%
10.8 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 20.6% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.1% · Q4 2.3% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
80.6%
19.4 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.7% |
21.2%
11.5 pts worse
|
23.9%
8.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 34.3% · Expected 25.0% · Used in QM five-star |
Survey summary
Top issue: Quality of Life and Care (5 deficiencies)
8 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-07-03
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-07-03
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-07-03
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-07-03
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-07-03
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 2024-07-03
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-07-03
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-07-03
Fire Safety
Meet other general requirements.
Corrected 2019-05-31
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-05-31
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2019-05-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-05-31
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-05-31
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-03-25
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-03-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-03-25
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2018-03-25
Inspection history
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 2024-06-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-18
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-06-18
Health
Respond appropriately to all alleged violations.
Corrected 2024-06-18
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-18
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-06-18
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-06-18
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 2024-06-18
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 2024-06-18
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2024-06-18
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-18
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-06-18
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-18
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 2024-06-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-18
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-06-18
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 2024-06-18
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-06-18
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-06-18
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-06-18
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-18
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 2024-06-18
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2024-06-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-06-18
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-18
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-06-18
Health
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Corrected 2024-06-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-07-03
Health
Provide and implement an infection prevention and control program.
Corrected 2019-07-03
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 2019-07-03
Health
Post nurse staffing information every day.
Corrected 2019-07-03
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2018-02-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-02-02
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2018-02-02
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 2018-02-02
Health
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Corrected 2018-02-02
Penalties and ownership
Fine · fine $47,254
Fine
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
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