Cycle 1
Health 2025-06-25 · Fire 2025-06-25
1 health deficiencies
Top issue: Resident Rights (1 deficiency)
5 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Baltimore, MD
Little Sisters Of The Poor
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
601 Maiden Choice Lane, Baltimore, MD
(410) 744-9367
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
20
Certified beds
Average residents
17
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2010-05-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
1.60
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.41
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
4.17
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
7.17
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
3.01
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
6.40
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
1.44
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
2.07
CMS adjusted RN staffing hours
Adjusted total hours
9.27
CMS adjusted total nurse staffing hours
Case-mix index
1.06
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 41% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 7 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 4 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 12.77% |
8.2%
4.6 pts better
|
Numerator 12 · Denominator 94 |
| Staff flu vaccination coverage | 54.17% |
42%
12.2 pts better
|
Numerator 52 · Denominator 96 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.9%
8.1 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.9% |
2.3%
3.6 pts worse
|
3.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
21.4%
21.4 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
5.7%
0.6 pts worse
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.6% |
16.1%
26.5 pts worse
|
19.6%
23 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 42.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 33.3% |
15.3%
18 pts worse
|
16.7%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 33.3% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.8% |
26.6%
7.8 pts better
|
16.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.3% |
22.9%
8.4 pts worse
|
14.9%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 31.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 8.5% |
0.7%
7.8 pts worse
|
1.0%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.0% |
1.5%
1.5 pts worse
|
1.7%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
25.4%
7 pts better
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 15.4% |
6.3%
9.1 pts worse
|
5.1%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 15.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-03-30 · Fire 2023-03-30
22 health deficiencies
Top issue: Resident Rights (6 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2019-01-04 · Fire 2019-01-04
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-06-25
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-08-25
F · Potential for more than minimal harm
2025-06-25
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-29
F · Potential for more than minimal harm
2025-06-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-25
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-08-25
D · Potential for more than minimal harm
2025-06-25
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 2025-08-25
E · Potential for more than minimal harm
2023-03-30
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-03-30
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 2023-05-26
D · Potential for more than minimal harm
2023-03-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-03-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-26
D · Potential for more than minimal harm
2023-03-30
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 2023-05-26
F · Potential for more than minimal harm
2019-01-04
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2019-04-23
F · Potential for more than minimal harm
2019-01-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-04-23
F · Potential for more than minimal harm
2019-01-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-04-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-06-25
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 2025-06-30
F · Potential for more than minimal harm
2023-03-30
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-05-15
F · Potential for more than minimal harm
2023-03-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-03-30
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 2023-05-15
E · Potential for more than minimal harm
2023-03-30
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-03-30
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 2023-05-15
E · Potential for more than minimal harm
2023-03-30
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 2023-05-15
E · Potential for more than minimal harm
2023-03-30
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2023-05-15
E · Potential for more than minimal harm
2023-03-30
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 2023-05-15
E · Potential for more than minimal harm
2023-03-30
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 2023-05-15
E · Potential for more than minimal harm
2023-03-30
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 2023-05-15
D · Potential for more than minimal harm
2023-03-30
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 2023-05-15
D · Potential for more than minimal harm
2023-03-30
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 2023-05-15
D · Potential for more than minimal harm
2023-03-30
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-30
F710 · Nursing and Physician Services Deficiencies
Health
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-30
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-30
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-30
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-15
D · Potential for more than minimal harm
2023-03-30
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-05-15
C · Minimal harm
2023-03-30
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-05-15
C · Minimal harm
2023-03-30
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 2023-05-15
C · Minimal harm
2023-03-30
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 2023-05-15
C · Minimal harm
2023-03-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-05-15
D · Potential for more than minimal harm
2019-01-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-03-12
D · Potential for more than minimal harm
2019-01-04
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 2019-03-12
Penalties and ownership
What sits behind the stars
Ownership
Brusche, Deborah
Operational/Managerial Control · Individual
Brusche, Deborah
Corporate Officer · Individual
Kleibusch, Lois
Operational/Managerial Control · Individual
Kleibusch, Lois
Corporate Officer · Individual
Piche, Marie
Operational/Managerial Control · Individual
Piche, Marie
Corporate Officer · Individual
Pocock, Barbara
Operational/Managerial Control · Individual
Pocock, Barbara
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Charlestown Community Inc
Catonsville, MD
5-star overall rating with 4-star inspections with $9,315 in total fines with 9 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Ridgeway Rehab Center
Catonsville, MD
3-star overall rating with 3-star inspections with $37,805 in total fines with 24 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Westgate Hills Rehab & Healthcare Ctr
Baltimore, MD
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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