Cycle 1
Health 2025-09-16 · Fire 2025-09-16
22 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Dundalk, MD
Complete Care At Heritage LLC
2-star overall rating with 1-star inspections with $129,919 in total fines with 22 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
7232 German Hill Road, Dundalk, MD
(410) 282-6310
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
177
Certified beds
Average residents
153
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1981-11-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
85 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
0.82
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.65
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.39
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.26
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
61%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,772
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.59
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.73
Baseline 20.35% · Performance 19.70% · Measure score 3.73 · Achievement 3.73 · Improvement 1.45
Healthcare-associated infections
0.55
Baseline 9.13% · Performance 8.70% · Measure score 0.55 · Achievement 0 · Improvement 0.55
Total nurse turnover
3.95
Baseline 63.19% · Performance 47.55% · Measure score 3.95 · Achievement 3.95 · Improvement 3.58
Adjusted total nurse staffing
0.81
Baseline 3.39 hours · Performance 3.31 hours · Measure score 0.81 · Achievement 0.81 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 286 · Observed rate 10.84% · Lower 95% interval 8.04% |
| Discharge to community | 53.01% |
50.57%
2.4 pts better
|
No Different than the National Rate · Eligible stays 272 · Observed rate 45.22% · Lower 95% interval 47.58% |
| Medicare spending per beneficiary | 1.11 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 211 · Denominator 211 |
| Falls with major injury | 0.95% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 211 |
| Discharge self-care score | 61.02% |
53.69%
7.3 pts better
|
Numerator 72 · Denominator 118 |
| Discharge mobility score | 56.78% |
50.94%
5.8 pts better
|
Numerator 67 · Denominator 118 |
| Pressure ulcers or injuries, new or worsened | 0.95% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 211 · Adjusted rate 1% |
| Healthcare-associated infections requiring hospitalization | 8.7% |
7.12%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 197 · Observed rate 9.64% · Lower 95% interval 6.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 75.63% |
42%
33.6 pts better
|
Numerator 121 · Denominator 160 |
| Discharge function score | 65.25% |
56.45%
8.8 pts better
|
Numerator 77 · Denominator 118 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 70 · Denominator 70 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 71 · Denominator 71 |
| Resident COVID-19 vaccinations up to date | 23.77% |
25.2%
1.4 pts worse
|
Numerator 29 · Denominator 122 |
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 1.6 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.2
0.2 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
91.9%
5.2 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.2% · Q2 100.0% · Q3 97.5% · Q4 92.2% · 4Q avg 97.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.6%
3.4 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.2% |
2.3%
1.1 pts better
|
3.3%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.8% · Q3 0.0% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 23.2% |
21.4%
1.8 pts worse
|
11.4%
11.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 20.7% · Q3 20.7% · Q4 26.1% · 4Q avg 23.2% |
| Percentage of long-stay residents who lose too much weight | 8.3% |
5.7%
2.6 pts worse
|
5.4%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.2% · Q2 13.4% · Q3 9.8% · Q4 3.5% · 4Q avg 8.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.8% |
16.1%
0.7 pts worse
|
19.6%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.1% · Q2 15.6% · Q3 17.4% · Q4 16.9% · 4Q avg 16.8% |
| 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 12.3% · Q2 13.2% · Q3 16.0% · Q4 9.2% · 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 | 24.8% |
26.6%
1.8 pts better
|
16.3%
8.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.1% · Q2 35.9% · Q3 13.0% · Q4 9.8% · 4Q avg 24.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
22.9%
3.1 pts better
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 30.4% · Q3 22.6% · Q4 8.5% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.7%
0.7 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.6% · Q3 1.2% · Q4 1.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.5%
0.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 1.7% · Q3 0.8% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.1% |
25.4%
1.3 pts better
|
19.8%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 23.0% · Q3 33.6% · Q4 18.0% · 4Q avg 24.1% |
| Percentage of long-stay residents with pressure ulcers | 4.7% |
6.3%
1.6 pts better
|
5.1%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.0% · Q3 5.0% · Q4 4.5% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.1% |
78.4%
25.3 pts worse
|
81.7%
28.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 60.8% · Q2 54.7% · Q3 46.0% · Q4 50.6% · 4Q avg 53.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
9.9%
1.9 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 8.6% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.3%
0.8 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 63.3% |
80.6%
17.3 pts worse
|
79.7%
16.4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 63.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.2% |
21.2%
3 pts better
|
23.9%
5.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.2% · Observed 18.8% · Expected 24.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-22 · Fire 2023-08-22
27 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2019-01-22 · Fire 2019-01-22
21 health deficiencies
Top issue: Pharmacy Service (6 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-09-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-12-29
F · Potential for more than minimal harm
2025-09-16
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-12-29
E · Potential for more than minimal harm
2025-09-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-29
E · Potential for more than minimal harm
2025-09-16
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-09-16
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 2025-12-29
D · Potential for more than minimal harm
2025-09-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-12-29
D · Potential for more than minimal harm
2025-09-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-12-29
F · Potential for more than minimal harm
2023-08-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-10
F · Potential for more than minimal harm
2023-08-22
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-09-10
F · Potential for more than minimal harm
2023-08-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-22
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-10-04
F · Potential for more than minimal harm
2023-08-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-09-10
F · Potential for more than minimal harm
2023-08-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-04
E · Potential for more than minimal harm
2023-08-22
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-08-22
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-08-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-09-10
D · Potential for more than minimal harm
2023-08-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-09-10
F · Potential for more than minimal harm
2019-01-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-04-15
E · Potential for more than minimal harm
2019-01-22
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-04-15
D · Potential for more than minimal harm
2019-01-22
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 2019-04-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-09-16
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 2025-10-29
E · Potential for more than minimal harm
2025-09-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-10-29
E · Potential for more than minimal harm
2025-09-16
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 2025-10-29
E · Potential for more than minimal harm
2025-09-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-29
E · Potential for more than minimal harm
2025-09-16
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-16
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 2025-10-29
D · Potential for more than minimal harm
2025-09-16
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 2025-10-29
D · Potential for more than minimal harm
2025-09-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-16
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 2025-10-29
D · Potential for more than minimal harm
2025-09-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-16
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 2025-10-29
D · Potential for more than minimal harm
2025-09-16
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 2025-10-29
D · Potential for more than minimal harm
2025-09-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-16
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 2025-10-29
D · Potential for more than minimal harm
2025-09-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-16
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-16
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 2025-10-29
D · Potential for more than minimal harm
2025-09-16
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 2025-10-29
D · Potential for more than minimal harm
2025-09-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-16
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2025-10-29
D · Potential for more than minimal harm
2025-09-16
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2025-10-29
C · Minimal harm
2025-09-16
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-10-29
J · Immediate jeopardy
2025-02-26
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-02
J · Immediate jeopardy
2023-08-22
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 2023-10-06
G · Actual harm
2023-08-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-08-22
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 2023-11-14
E · Potential for more than minimal harm
2023-08-22
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 2023-10-06
E · Potential for more than minimal harm
2023-08-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-14
E · Potential for more than minimal harm
2023-08-22
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 2023-10-06
E · Potential for more than minimal harm
2023-08-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-08-22
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 2023-11-14
E · Potential for more than minimal harm
2023-08-22
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
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 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
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 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
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 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
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 2023-11-14
D · Potential for more than minimal harm
2023-08-22
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
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 2023-11-14
D · Potential for more than minimal harm
2023-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-08-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F940 · Administration Deficiencies
Health
Develop, implement, and/or maintain an effective training program for all new and existing staff members.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-22
F949 · Administration Deficiencies
Health
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-04-14
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 2023-05-19
D · Potential for more than minimal harm
2023-04-14
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-04-14
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 2023-05-19
E · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
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 2019-03-08
D · Potential for more than minimal harm
2019-01-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-03-08
Penalties and ownership
What sits behind the stars
$60,132
2025-02-26
Fine
Fine · fine $60,132
Fine
$69,787
2023-08-22
Fine
Fine · fine $69,787
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
General Partnership Interest · Individual
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