20 health deficiencies
Top issue: Administration (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Baltimore, MD
2-star overall rating with 3-star inspections with 20 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
2801 Rayner Avenue, Baltimore, MD
(410) 945-7650
Overall
2 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
29
Certified beds
Average residents
22
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-08-21
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
RN hours / resident day
0.64
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.85
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.54
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.49
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.73
CMS adjusted RN staffing hours
Adjusted total hours
4.05
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
29%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
3,362
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.73
Composite VBP score used to determine payment impact.
Payment multiplier
0.9979
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.42
Baseline 34.78% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 0.96
Adjusted total nurse staffing
1.52
Performance 3.51 hours · Measure score 1.52 · Achievement 1.52 · This facility did not have sufficient data to calculate a baseline period measure result.
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 3 · 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 1 · 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 2 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 2 · 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 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · 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 2 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 47.3% |
91.9%
44.6 pts worse
|
93.4%
46.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.4% · Q2 47.8% · Q3 47.8% · Q4 50.0% · 4Q avg 47.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.5% |
96.6%
8.1 pts worse
|
95.5%
7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
2.3%
2.3 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.3% |
21.4%
20.1 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.7%
0.5 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q3 4.8% · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.4% |
16.1%
10.3 pts worse
|
19.6%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 28.6% · Q3 28.6% · 4Q avg 26.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 48.6% |
15.3%
33.3 pts worse
|
16.7%
31.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 48.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.2% |
26.6%
16.4 pts better
|
16.3%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 22.8% |
22.9%
0.1 pts better
|
14.9%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 33.3% · 4Q avg 22.8% · 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 | 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 | 19.3% |
25.4%
6.1 pts better
|
19.8%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 18.5% · Q3 32.1% · Q4 20.3% · 4Q avg 19.3% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.3%
0.1 pts better
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 8.5% · Q3 7.1% · Q4 3.9% · 4Q avg 6.2% · Used in QM five-star |
Survey summary
Top issue: Administration (4 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Nursing and Physician Services (3 deficiencies)
18 fire-safety deficiencies
Top issue: Smoke (9 deficiencies)
Top issue: Environmental (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-05
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-09-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-09-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-09-05
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-09-05
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-09-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-09-05
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2025-09-05
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2025-09-05
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-01-06
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-01-06
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-01-06
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2023-01-06
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-01-06
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-08-31
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-01-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-06
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-01-06
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-31
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2022-08-31
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-08-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-31
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-01-06
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-31
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-08-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-01-06
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-08-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-06-04
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2019-06-04
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2019-06-04
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2019-06-04
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-08-03
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-08-03
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-08-03
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-08-03
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-08-03
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-08-03
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-03
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-03
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-08-03
Health
Assess the resident when there is a significant change in condition
Corrected 2025-08-03
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2025-08-03
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-08-03
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-08-03
Health
Provide activities to meet all resident's needs.
Corrected 2025-08-03
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 2025-08-03
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-08-03
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-03
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2025-08-03
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-03
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-08-03
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 2022-08-28
Health
Post nurse staffing information every day.
Corrected 2022-08-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-28
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-08-28
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-28
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-28
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2022-08-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-28
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2022-08-28
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2022-08-28
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2022-08-28
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 2022-08-28
Health
Provide or obtain dental services for each resident.
Corrected 2022-08-28
Health
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
Corrected 2022-08-28
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-28
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2022-08-28
Health
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Corrected 2022-08-28
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2022-08-28
Health
Put firmly secured handrails on each side of hallways.
Corrected 2022-08-28
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-05-24
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 2019-05-24
Health
Provide or obtain dental services for each resident.
Corrected 2019-05-24
Health
Keep all essential equipment working safely.
Corrected 2019-05-24
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2019-05-24
Penalties and ownership
Corporate Officer · Individual
W-2 Managing Employee · Individual
Corporate Officer · Individual
Corporate Officer · Individual
Nearby options
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