Cycle 1
Health 2025-08-28 · Fire 2025-08-28
30 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
11 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Catonsville, MD
Frederick Villa Healthcare
3-star overall rating with 2-star inspections with 30 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
711 Academy Road, Catonsville, MD
(410) 788-3300
Overall
3 / 5
CMS overall stars
Health inspections
2 / 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
125
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Engage Healthcare
Operator or chain grouping
Approved since
1989-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
5 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.50
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.90
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.49
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
59%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,689
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.95
Composite VBP score used to determine payment impact.
Payment multiplier
0.9920
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.70
Baseline 19.30% · Performance 18.33% · Measure score 6.70 · Achievement 6.70 · Improvement 3.79
Healthcare-associated infections
3.89
Baseline 5.64% · Performance 6.67% · Measure score 3.89 · Achievement 3.89 · Improvement 0
Total nurse turnover
4.99
Baseline 43.21% · Performance 43.30% · Measure score 4.99 · Achievement 4.99 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.28 hours · Performance 3.18 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.08% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 135 · Observed rate 15.56% · Lower 95% interval 8.93% |
| Discharge to community | 36.96% |
50.57%
13.6 pts worse
|
Worse than the National Rate · Eligible stays 115 · Observed rate 26.96% · Lower 95% interval 28.01% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.73% |
95.27%
3.5 pts better
|
Numerator 78 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 53.85% |
53.69%
0.2 pts better
|
Numerator 28 · Denominator 52 |
| Discharge mobility score | 48.08% |
50.94%
2.9 pts worse
|
Numerator 25 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 79 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.67% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 6.41% · Lower 95% interval 3.96% |
| Staff COVID-19 vaccination coverage | 1.32% |
8.2%
6.9 pts worse
|
Numerator 2 · Denominator 151 |
| Staff flu vaccination coverage | 25.95% |
42%
16.1 pts worse
|
Numerator 48 · Denominator 185 |
| Discharge function score | 57.69% |
56.45%
1.2 pts better
|
Numerator 30 · Denominator 52 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 92.59% |
96.28%
3.7 pts worse
|
Numerator 25 · Denominator 27 |
| Resident COVID-19 vaccinations up to date | 12.82% |
25.2%
12.4 pts worse
|
Numerator 5 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.3
0.2 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.7 |
1.2
0.5 pts better
|
1.8
1.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 0.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.7% |
91.9%
18.2 pts worse
|
93.4%
19.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 67.0% · Q2 70.6% · Q3 74.5% · Q4 82.8% · 4Q avg 73.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 84.8% |
96.6%
11.8 pts worse
|
95.5%
10.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.5% |
2.3%
1.2 pts worse
|
3.3%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 3.9% · Q3 2.9% · Q4 2.0% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 39.5% |
21.4%
18.1 pts worse
|
11.4%
28.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 30.2% · Q3 47.9% · Q4 47.1% · 4Q avg 39.5% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
5.7%
1.3 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 2.1% · Q3 4.2% · Q4 4.2% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.0% |
16.1%
6.9 pts worse
|
19.6%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.5% · Q2 26.0% · Q3 21.0% · Q4 18.4% · 4Q avg 23.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.9% |
15.3%
7.4 pts better
|
16.7%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 10.3% · Q3 9.0% · Q4 7.1% · 4Q avg 7.9% · 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 | 33.7% |
26.6%
7.1 pts worse
|
16.3%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 44.0% · Q3 25.5% · Q4 47.0% · 4Q avg 33.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.6% |
22.9%
3.7 pts worse
|
14.9%
11.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 30.9% · Q3 22.4% · Q4 35.4% · 4Q avg 26.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.5% |
1.5%
About the same
|
1.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 3.0% · Q4 2.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.6% |
25.4%
2.2 pts worse
|
19.8%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 29.0% · Q3 29.7% · Q4 26.2% · 4Q avg 27.6% |
| Percentage of long-stay residents with pressure ulcers | 8.4% |
6.3%
2.1 pts worse
|
5.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 5.5% · Q3 9.4% · Q4 10.8% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 55.4% |
78.4%
23 pts worse
|
81.7%
26.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 44.0% · Q3 58.5% · Q4 76.7% · 4Q avg 55.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.0% |
9.9%
4.9 pts better
|
12.0%
7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.0% · Observed 6.0% · Expected 13.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.7% |
1.3%
1.4 pts worse
|
1.6%
1.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 3.8% · Q4 3.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 42.9% |
80.6%
37.7 pts worse
|
79.7%
36.8 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 42.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.1% |
21.2%
9.1 pts better
|
23.9%
11.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 15.7% · Expected 30.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-04-13 · Fire 2023-04-13
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2019-05-28 · Fire 2019-05-28
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 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
2025-08-28
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-10-25
F · Potential for more than minimal harm
2025-08-28
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2025-10-25
F · Potential for more than minimal harm
2025-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-25
F · Potential for more than minimal harm
2025-08-28
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2025-10-25
E · Potential for more than minimal harm
2025-08-28
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 2025-10-25
E · Potential for more than minimal harm
2025-08-28
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-10-25
E · Potential for more than minimal harm
2025-08-28
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 2025-10-25
E · Potential for more than minimal harm
2025-08-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-25
E · Potential for more than minimal harm
2025-08-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-08-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-10-25
D · Potential for more than minimal harm
2025-08-28
K754 · Miscellaneous Deficiencies
Fire Safety
Provide properly sized and located linen or trash receptacles.
Corrected 2025-10-25
E · Potential for more than minimal harm
2023-04-13
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 2023-07-05
E · Potential for more than minimal harm
2023-04-13
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 2023-07-05
E · Potential for more than minimal harm
2023-04-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-04-13
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-04-13
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-05
E · Potential for more than minimal harm
2023-04-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
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 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-07-05
D · Potential for more than minimal harm
2023-04-13
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-07-05
E · Potential for more than minimal harm
2019-05-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-28
K300 · Egress Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-28
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-28
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-06-14
C · Minimal harm
2019-05-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-06-14
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-28
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2025-10-03
F · Potential for more than minimal harm
2025-08-28
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-08-28
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 2025-10-03
E · Potential for more than minimal harm
2025-08-28
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2025-10-03
E · Potential for more than minimal harm
2025-08-28
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 2025-10-03
E · Potential for more than minimal harm
2025-08-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F628 · Resident Rights Deficiencies
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F730 · Nursing and Physician Services Deficiencies
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2025-10-03
D · Potential for more than minimal harm
2025-08-28
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 2025-10-03
D · Potential for more than minimal harm
2025-08-28
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2025-10-03
F · Potential for more than minimal harm
2023-04-13
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 2023-06-12
E · Potential for more than minimal harm
2023-04-13
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 2023-06-12
E · Potential for more than minimal harm
2023-04-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-04-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-04-13
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-04-13
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 2023-06-12
D · Potential for more than minimal harm
2023-04-13
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-04-13
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-04-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-04-13
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-12
D · Potential for more than minimal harm
2023-04-13
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 2023-06-12
B · Minimal harm
2023-04-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-06-12
E · Potential for more than minimal harm
2019-05-28
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
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 2019-07-11
D · Potential for more than minimal harm
2019-05-28
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
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 2019-07-11
D · Potential for more than minimal harm
2019-05-28
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 2019-07-11
D · Potential for more than minimal harm
2019-05-28
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 2019-07-11
D · Potential for more than minimal harm
2019-05-28
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 2019-07-11
D · Potential for more than minimal harm
2019-05-28
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
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 2019-07-11
D · Potential for more than minimal harm
2019-05-28
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
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 2019-07-11
D · Potential for more than minimal harm
2019-05-28
F800 · Nutrition and Dietary Deficiencies
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2019-07-11
D · Potential for more than minimal harm
2019-05-28
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 2019-07-11
Penalties and ownership
What sits behind the stars
Ownership
Academy Md Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Lighten, Jake
5% Or Greater Indirect Ownership Interest · Individual
Paneth, Jack
5% Or Greater Indirect Ownership Interest · Individual
Lighten, Jake
Operational/Managerial Control · Individual
Loloyan, Elisha
W-2 Managing Employee · Individual
Paneth, Jack
Corporate Officer · Individual
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#3
Westgate Hills Rehab & Healthcare Ctr
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1-star overall rating with 2-star inspections with 28 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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