Cycle 1
Health 2024-07-12 · Fire 2024-07-12
6 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Centreville, MD
Complete Care at Corsica Hills LLC
2-star overall rating with 2-star inspections with abuse icon flag with $55,564 in total fines with 6 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
205 Armstrong Street, Centreville, MD
(410) 758-2323
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1978-11-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.86
Registered nurse staffing
LPN hours / resident day
0.48
Licensed practical nurse staffing
Aide hours / resident day
2.19
Nurse aide staffing
Weekend hours
3.19
Weekend nurse staffing
RN turnover
35%
Annual RN turnover
Total nurse turnover
50%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.6 |
1.3
0.7 pts better
|
1.9
1.3 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.0% |
91.9%
6.1 pts better
|
93.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
2.3%
0.8 pts worse
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 27.0% |
21.4%
5.6 pts worse
|
11.4%
15.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 5.5% |
5.7%
0.2 pts better
|
5.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
16.1%
9.9 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 8.3% |
15.3%
7 pts better
|
16.7%
8.4 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 | 32.9% |
26.6%
6.3 pts worse
|
16.3%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.5% |
22.9%
3.6 pts worse
|
14.9%
11.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.7%
0.3 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.5%
1.1 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.0% |
25.4%
0.6 pts worse
|
19.8%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
6.3%
1.3 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.0% |
78.4%
10.6 pts better
|
81.7%
7.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.7% |
9.9%
5.8 pts worse
|
12.0%
3.7 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.3% |
1.3%
1 pts worse
|
1.6%
0.7 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.2% |
80.6%
11.6 pts better
|
79.7%
12.5 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
21.2%
3.6 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-24 · Fire 2019-05-24
18 health deficiencies
Top issue: Resident Rights (6 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2018-01-19 · Fire 2018-01-19
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-12
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-09-04
F · Potential for more than minimal harm
2024-07-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-12
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-12
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-12
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 2024-09-04
E · Potential for more than minimal harm
2024-07-12
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-12
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-09-04
E · Potential for more than minimal harm
2024-07-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-12
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 2024-09-04
D · Potential for more than minimal harm
2024-07-12
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2024-09-04
F · Potential for more than minimal harm
2019-05-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-08-15
F · Potential for more than minimal harm
2019-05-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-06-27
F · Potential for more than minimal harm
2019-05-24
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-06-19
F · Potential for more than minimal harm
2019-05-24
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2019-07-03
F · Potential for more than minimal harm
2019-05-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2019-07-03
F · Potential for more than minimal harm
2019-05-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-06-18
E · Potential for more than minimal harm
2019-05-24
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-07-03
D · Potential for more than minimal harm
2019-05-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-07-03
F · Potential for more than minimal harm
2018-01-19
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2018-04-30
D · Potential for more than minimal harm
2018-01-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-04-30
Inspection history
Recent health citations
K · Immediate jeopardy
2024-07-12
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 2024-08-22
F · Potential for more than minimal harm
2024-07-12
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-08-22
E · Potential for more than minimal harm
2024-07-12
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 2024-08-22
E · Potential for more than minimal harm
2024-07-12
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-07-12
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 2024-08-22
D · Potential for more than minimal harm
2024-07-12
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-22
D · Potential for more than minimal harm
2024-07-12
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 2024-08-22
D · Potential for more than minimal harm
2024-07-12
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 2024-08-22
D · Potential for more than minimal harm
2024-07-12
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 2024-08-22
D · Potential for more than minimal harm
2024-07-12
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 2024-08-22
D · Potential for more than minimal harm
2024-07-12
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2024-08-22
C · Minimal harm
2024-07-12
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-08-22
E · Potential for more than minimal harm
2019-05-24
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-07-08
E · Potential for more than minimal harm
2019-05-24
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-24
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 2019-07-08
D · Potential for more than minimal harm
2019-05-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-24
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 2019-07-08
D · Potential for more than minimal harm
2019-05-24
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 2019-07-08
D · Potential for more than minimal harm
2019-05-24
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 2019-07-08
D · Potential for more than minimal harm
2019-05-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-24
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 2019-07-08
D · Potential for more than minimal harm
2019-05-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-24
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2019-07-08
D · Potential for more than minimal harm
2019-05-24
F924 · Environmental Deficiencies
Health
Put firmly secured handrails on each side of hallways.
Corrected 2019-07-08
E · Potential for more than minimal harm
2018-01-19
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 2018-02-28
E · Potential for more than minimal harm
2018-01-19
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 2018-02-28
D · Potential for more than minimal harm
2018-01-19
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 2018-02-28
D · Potential for more than minimal harm
2018-01-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-02-28
D · Potential for more than minimal harm
2018-01-19
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2018-02-28
D · Potential for more than minimal harm
2018-01-19
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2018-02-28
Penalties and ownership
What sits behind the stars
$55,564
2024-07-12
Fine
Fine · fine $55,564
Fine
Ownership
Pc Md Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Silverberg, Nisanel
Corporate Officer · Individual
Silverberg, Nisanel
W-2 Managing Employee · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
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