Cycle 1
Health 2025-03-24 · Fire 2025-03-24
28 health deficiencies
Top issue: Resident Rights (11 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Laplata, MD
Complete Care At Laplata LLC
2-star overall rating with 2-star inspections with $27,573 in total fines with 28 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
1 Magnolia Drive, Laplata, MD
(301) 934-4001
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
142
Certified beds
Average residents
129
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1984-03-19
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
0.71
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.73
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.20
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.53
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
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
34%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,154
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
37.23
Composite VBP score used to determine payment impact.
Payment multiplier
0.9905
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.14
Baseline 20.46% · Performance 18.58% · Measure score 6.14 · Achievement 6.14 · Improvement 4.96
Healthcare-associated infections
2.88
Baseline 8.31% · Performance 7.19% · Measure score 2.88 · Achievement 2.16 · Improvement 2.88
Total nurse turnover
5.27
Baseline 57.14% · Performance 42.15% · Measure score 5.27 · Achievement 5.27 · Improvement 4.14
Adjusted total nurse staffing
0.60
Baseline 3.33 hours · Performance 3.25 hours · Measure score 0.60 · Achievement 0.60 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.41% |
10.72%
2.7 pts worse
|
Worse than the National Rate · Eligible stays 219 · Observed rate 16.89% · Lower 95% interval 10.88% |
| Discharge to community | 53.1% |
50.57%
2.5 pts better
|
No Different than the National Rate · Eligible stays 228 · Observed rate 43.42% · Lower 95% interval 45.32% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 121 · Denominator 121 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 121 |
| Discharge self-care score | 66.15% |
53.69%
12.5 pts better
|
Numerator 43 · Denominator 65 |
| Discharge mobility score | 61.54% |
50.94%
10.6 pts better
|
Numerator 40 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 5.79% |
2.29%
3.5 pts worse
|
Numerator 7 · Denominator 121 · Adjusted rate 4.86% |
| Healthcare-associated infections requiring hospitalization | 7.19% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 7.89% · Lower 95% interval 4.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 75.21% |
42%
33.2 pts better
|
Numerator 88 · Denominator 117 |
| Discharge function score | 72.31% |
56.45%
15.9 pts better
|
Numerator 47 · Denominator 65 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 47 · Denominator 47 |
| Transfer of health information to patient | 98.31% |
96.28%
2 pts better
|
Numerator 58 · Denominator 59 |
| Resident COVID-19 vaccinations up to date | 7.14% |
25.2%
18.1 pts worse
|
Numerator 5 · Denominator 70 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
91.9%
7.6 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 99.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| 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 | 1.8% |
2.3%
0.5 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 2.9% · Q4 0.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 57.9% |
21.4%
36.5 pts worse
|
11.4%
46.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 61.3% · Q2 58.8% · Q3 60.0% · Q4 51.5% · 4Q avg 57.9% |
| Percentage of long-stay residents who lose too much weight | 6.6% |
5.7%
0.9 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 5.1% · Q3 7.6% · Q4 4.7% · 4Q avg 6.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
16.1%
4 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 11.4% · Q3 11.5% · Q4 12.3% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.2% |
15.3%
10.1 pts better
|
16.7%
11.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 5.2% · Q3 4.8% · Q4 4.6% · 4Q avg 5.2% · 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 | 21.2% |
26.6%
5.4 pts better
|
16.3%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 28.0% · Q3 27.9% · Q4 19.0% · 4Q avg 21.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.6% |
22.9%
11.3 pts better
|
14.9%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 12.1% · Q3 17.6% · Q4 13.5% · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.7%
0.5 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
1.5%
0.1 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.8% · Q3 0.0% · Q4 1.9% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.2% |
25.4%
4.8 pts worse
|
19.8%
10.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 31.1% · Q3 33.7% · Q4 31.4% · 4Q avg 30.2% |
| Percentage of long-stay residents with pressure ulcers | 7.0% |
6.3%
0.7 pts worse
|
5.1%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 8.2% · Q3 7.8% · Q4 6.7% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
78.4%
13 pts better
|
81.7%
9.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 92.4% · Q3 92.2% · Q4 87.2% · 4Q avg 91.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.6% |
9.9%
5.7 pts worse
|
12.0%
3.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.6% · Observed 14.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.6% |
80.6%
14 pts better
|
79.7%
14.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
21.2%
1.7 pts worse
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 25.7% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2020-01-30 · Fire 2020-01-30
20 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-07-27 · Fire 2018-07-27
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
6 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
2025-03-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-03-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-03-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-03-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-03-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-03-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-23
F · Potential for more than minimal harm
2025-03-24
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 2025-05-23
F · Potential for more than minimal harm
2025-03-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-03-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-03-24
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 2025-05-07
E · Potential for more than minimal harm
2025-03-24
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 2025-05-23
D · Potential for more than minimal harm
2025-03-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-07
D · Potential for more than minimal harm
2020-01-30
K241 · Egress Deficiencies
Fire Safety
Have correct number of accessible exits for each story.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-03-10
D · Potential for more than minimal harm
2020-01-30
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-03-10
C · Minimal harm
2020-01-30
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2020-03-10
F · Potential for more than minimal harm
2018-07-27
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-09-14
D · Potential for more than minimal harm
2018-07-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2018-09-14
D · Potential for more than minimal harm
2018-07-27
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 2018-09-14
D · Potential for more than minimal harm
2018-07-27
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 2018-09-14
D · Potential for more than minimal harm
2018-07-27
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 2018-09-14
D · Potential for more than minimal harm
2018-07-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-09-14
Inspection history
Recent health citations
G · Actual harm
2026-01-09
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 2026-02-06
E · Potential for more than minimal harm
2026-01-09
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 2026-02-06
D · Potential for more than minimal harm
2026-01-09
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 2026-02-06
D · Potential for more than minimal harm
2026-01-09
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 2026-02-06
D · Potential for more than minimal harm
2026-01-09
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 2026-02-06
D · Potential for more than minimal harm
2026-01-09
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-09
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 2026-02-06
D · Potential for more than minimal harm
2026-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-06
D · Potential for more than minimal harm
2026-01-09
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 2026-02-06
D · Potential for more than minimal harm
2026-01-09
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 2026-02-06
B · Minimal harm
2026-01-09
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-04-10
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 2025-05-16
D · Potential for more than minimal harm
2025-04-10
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 2025-05-16
D · Potential for more than minimal harm
2025-04-10
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-10
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 2025-05-16
D · Potential for more than minimal harm
2025-04-10
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2025-05-16
G · Actual harm
2025-03-24
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 2025-02-24
F · Potential for more than minimal harm
2025-03-24
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 2025-05-02
F · Potential for more than minimal harm
2025-03-24
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 2025-05-02
F · Potential for more than minimal harm
2025-03-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-02
E · Potential for more than minimal harm
2025-03-24
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-24
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 2025-05-02
D · Potential for more than minimal harm
2025-03-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-24
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 2025-05-02
D · Potential for more than minimal harm
2025-03-24
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-02
D · Potential for more than minimal harm
2025-03-24
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2025-05-02
F · Potential for more than minimal harm
2024-12-04
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-12-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-14
E · Potential for more than minimal harm
2024-12-04
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 2025-01-14
D · Potential for more than minimal harm
2024-12-04
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 2025-01-14
D · Potential for more than minimal harm
2024-12-04
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 2025-01-14
D · Potential for more than minimal harm
2024-12-04
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-04
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-04
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 2025-01-14
D · Potential for more than minimal harm
2024-12-04
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 2025-01-14
D · Potential for more than minimal harm
2024-12-04
F699 · Quality of Life and Care Deficiencies
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-04
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 2025-01-14
D · Potential for more than minimal harm
2024-12-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-04
F773 · Administration Deficiencies
Health
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-04
F775 · Administration Deficiencies
Health
Keep complete, dated laboratory records in the resident's record.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-04
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-04
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2025-01-14
D · Potential for more than minimal harm
2024-12-04
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 2025-01-14
D · Potential for more than minimal harm
2020-01-30
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2020-03-06
D · Potential for more than minimal harm
2020-01-30
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 2020-03-06
E · Potential for more than minimal harm
2018-07-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2018-09-21
E · Potential for more than minimal harm
2018-07-27
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2018-09-21
D · Potential for more than minimal harm
2018-07-27
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2018-09-21
D · Potential for more than minimal harm
2018-07-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-09-21
D · Potential for more than minimal harm
2018-07-27
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2018-09-21
D · Potential for more than minimal harm
2018-07-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-09-21
D · Potential for more than minimal harm
2018-07-27
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 2018-09-21
D · Potential for more than minimal harm
2018-07-27
F840 · Administration Deficiencies
Health
Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
Corrected 2018-09-21
D · Potential for more than minimal harm
2018-07-27
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 2018-09-21
Penalties and ownership
What sits behind the stars
$17,215
2026-01-09
Fine
Fine · fine $17,215
Fine
$10,358
2025-03-24
Fine
Fine · fine $10,358
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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3-star overall rating with 3-star inspections with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#3
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4-star overall rating with 3-star inspections with 18 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
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