Cycle 1
Health 2024-11-08 · Fire 2024-11-08
11 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Towson, MD
Complete Care At Multi Medical Center LLC
5-star overall rating with 4-star inspections with 11 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
7700 York Road, Towson, MD
(410) 821-5500
Overall
5 / 5
CMS overall stars
Health inspections
4 / 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
118
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Complete Care
Operator or chain grouping
Approved since
1974-06-01
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
0.89
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.22
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.96
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.08
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
2.12
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.68
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.66
CMS adjusted RN staffing hours
Adjusted total hours
3.02
CMS adjusted total nurse staffing hours
Case-mix index
1.85
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,292
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9858
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.35
Baseline 22.14% · Performance 20.17% · Measure score 3.35 · Achievement 2.71 · Improvement 3.35
Healthcare-associated infections
3.21
Baseline 6.36% · Performance 6.88% · Measure score 3.21 · Achievement 3.21 · Improvement 0
Total nurse turnover
4.76
Baseline 72.88% · Performance 47.62% · Measure score 4.76 · Achievement 3.93 · Improvement 4.76
Adjusted total nurse staffing
0.75
Baseline 3.68 hours · Performance 3.29 hours · Measure score 0.75 · Achievement 0.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.26% |
10.72%
3.5 pts worse
|
Worse than the National Rate · Eligible stays 612 · Observed rate 14.87% · Lower 95% interval 11.94% |
| Discharge to community | 60.82% |
50.57%
10.2 pts better
|
Better than the National Rate · Eligible stays 648 · Observed rate 52.31% · Lower 95% interval 55.83% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 99.76% |
95.27%
4.5 pts better
|
Numerator 420 · Denominator 421 |
| Falls with major injury | 0.95% |
0.77%
0.2 pts worse
|
Numerator 4 · Denominator 421 |
| Discharge self-care score | 61.86% |
53.69%
8.2 pts better
|
Numerator 146 · Denominator 236 |
| Discharge mobility score | 62.29% |
50.94%
11.4 pts better
|
Numerator 147 · Denominator 236 |
| Pressure ulcers or injuries, new or worsened | 1.9% |
2.29%
0.4 pts better
|
Numerator 8 · Denominator 421 · Adjusted rate 1.5% |
| Healthcare-associated infections requiring hospitalization | 6.88% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 429 · Observed rate 6.99% · Lower 95% interval 4.88% |
| Staff COVID-19 vaccination coverage | 2.17% |
8.2%
6 pts worse
|
Numerator 3 · Denominator 138 |
| Staff flu vaccination coverage | 79.82% |
42%
37.8 pts better
|
Numerator 91 · Denominator 114 |
| Discharge function score | 70.34% |
56.45%
13.9 pts better
|
Numerator 166 · Denominator 236 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 356 · Denominator 356 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 29 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 14.98% |
25.2%
10.2 pts worse
|
Numerator 31 · Denominator 207 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.9 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.2
About the same
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.3 · Expected 1.9 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
91.9%
7 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 100.0% · Q4 97.3% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
96.6%
2.1 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
2.3%
1.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 4.3% · Q3 4.5% · Q4 2.7% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 73.1% |
21.4%
51.7 pts worse
|
11.4%
61.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 51.9% · Q2 45.6% · Q3 93.3% · Q4 95.5% · 4Q avg 73.1% |
| Percentage of long-stay residents who lose too much weight | 8.9% |
5.7%
3.2 pts worse
|
5.4%
3.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 7.7% · Q3 9.5% · Q4 8.8% · 4Q avg 8.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.2% |
16.1%
4.1 pts worse
|
19.6%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 19.4% · Q3 23.1% · Q4 21.4% · 4Q avg 20.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
15.3%
8.6 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 7.7% · Q3 2.0% · Q4 5.3% · 4Q avg 6.7% · 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 | 19.3% |
26.6%
7.3 pts better
|
16.3%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.6% |
22.9%
10.3 pts better
|
14.9%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.3% · Q2 18.2% · Q3 14.0% · Q4 7.0% · 4Q avg 12.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.7%
0.3 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.5%
1.5 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.1% |
25.4%
1.7 pts worse
|
19.8%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.0% · Q2 16.2% · Q3 20.0% · Q4 38.0% · 4Q avg 27.1% |
| Percentage of long-stay residents with pressure ulcers | 10.7% |
6.3%
4.4 pts worse
|
5.1%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 13.3% · Q3 12.6% · Q4 6.3% · 4Q avg 10.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.5% |
78.4%
1.9 pts worse
|
81.7%
5.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.2% · Q2 85.0% · Q3 72.1% · Q4 72.4% · 4Q avg 76.5% |
| 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 7.5% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.3%
0.3 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 1.1% · Q3 0.6% · Q4 0.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.5% |
80.6%
6.9 pts better
|
79.7%
7.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.1% |
21.2%
0.9 pts worse
|
23.9%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 22.0% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-08-23 · Fire 2019-08-23
11 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2018-05-03 · Fire 2018-05-03
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-11-08
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-08
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-01-02
F · Potential for more than minimal harm
2024-11-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-08
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-08
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 2025-01-02
E · Potential for more than minimal harm
2024-11-08
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-01-02
E · Potential for more than minimal harm
2024-11-08
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-08
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-08
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-08
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-01-02
D · Potential for more than minimal harm
2024-11-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-01-02
D · Potential for more than minimal harm
2019-08-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2019-09-27
D · Potential for more than minimal harm
2019-08-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2019-09-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-08
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 2024-12-20
D · Potential for more than minimal harm
2024-11-08
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-08
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-08
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 2024-12-20
D · Potential for more than minimal harm
2024-11-08
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-08
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-08
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-08
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 2024-12-20
E · Potential for more than minimal harm
2019-08-23
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 2019-09-20
E · Potential for more than minimal harm
2019-08-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-09-20
E · Potential for more than minimal harm
2019-08-23
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2019-09-20
D · Potential for more than minimal harm
2019-08-23
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-09-20
D · Potential for more than minimal harm
2019-08-23
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 2019-09-20
D · Potential for more than minimal harm
2019-08-23
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 2019-09-20
D · Potential for more than minimal harm
2019-08-23
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 2019-09-20
D · Potential for more than minimal harm
2019-08-23
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 2019-09-20
D · Potential for more than minimal harm
2019-08-23
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-09-20
D · Potential for more than minimal harm
2019-08-23
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 2019-09-20
D · Potential for more than minimal harm
2019-08-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2019-09-20
E · Potential for more than minimal harm
2018-05-03
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 2018-05-23
D · Potential for more than minimal harm
2018-05-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2018-05-23
D · Potential for more than minimal harm
2018-05-03
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 2018-05-23
D · Potential for more than minimal harm
2018-05-03
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2018-05-23
Penalties and ownership
What sits behind the stars
Ownership
Pc Md Opcos LLC
5% Or Greater Direct Ownership Interest · Organization
Cox, Vickie
Operational/Managerial Control · Individual
Mansfield, Melissa
Operational/Managerial Control · Individual
Odachowski, Stacie
Operational/Managerial Control · Individual
Pc Wta Opco Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Peace Capital Holdings LLC (De)
5% Or Greater Indirect Ownership Interest · Organization
Rizqui, Ibrahim
Operational/Managerial Control · Individual
Silverberg, Nisanel
Operational/Managerial Control · Individual
Sms 2021 Trust
5% Or Greater Indirect Ownership Interest · Organization
Stein, Shalom
Corporate Officer · Individual
Welltower Op LLC
5% Or Greater Security Interest · Organization
Nearby options
Other facilities in reach
#1
Holly Hill Healthcare Center
Towson, MD
2-star overall rating with 1-star inspections with abuse icon flag with 33 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#2
Towson Rehabilitation And Healthcare Center
Towson, MD
5-star overall rating with 4-star inspections with $10,036 in total fines with 8 recent health deficiencies with 20 fire-safety deficiencies in the latest cycle
#3
Edenwald
Towson, MD
5-star overall rating with 5-star inspections with 6 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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