Westernport, MD
3-star overall rating with 3-star inspections with 13 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
25701 Shady Lane Southwest, Westernport, MD
(301) 359-3000
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
130
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
1992-08-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
69 facilities
Chain averages 2 overall / 2 health / 2 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
RN hours / resident day
0.63
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.38
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
4.01
CMS adjusted total nurse staffing hours
Case-mix index
1.13
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
4,636
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
39.15
Composite VBP score used to determine payment impact.
Payment multiplier
0.9922
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.06
Baseline 20.69% · Performance 18.62% · Measure score 6.06 · Achievement 6.06 · Improvement 5.14
Healthcare-associated infections
1.93
Baseline 6.66% · Performance 7.26% · Measure score 1.93 · Achievement 1.93 · Improvement 0
Total nurse turnover
5.79
Baseline 38.00% · Performance 40.00% · Measure score 5.79 · Achievement 5.79 · Improvement 0
Adjusted total nurse staffing
1.89
Baseline 3.85 hours · Performance 3.61 hours · Measure score 1.89 · Achievement 1.89 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.86% |
10.72%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 110 · Observed rate 11.82% · Lower 95% interval 7.99% |
| Discharge to community | 50.73% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 42.39% · Lower 95% interval 39.98% |
| Medicare spending per beneficiary | 1.12 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.53% |
95.27%
2.3 pts better
|
Numerator 79 · Denominator 81 |
| Falls with major injury | 1.23% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 81 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 35 · Denominator 55 |
| Discharge mobility score | 52.73% |
50.94%
1.8 pts better
|
Numerator 29 · Denominator 55 |
| Pressure ulcers or injuries, new or worsened | 8.64% |
2.29%
6.4 pts worse
|
Numerator 7 · Denominator 81 · Adjusted rate 8.21% |
| Healthcare-associated infections requiring hospitalization | 7.26% |
7.12%
0.1 pts worse
|
No Different than the National Rate · Eligible stays 69 · Observed rate 8.7% · Lower 95% interval 4.28% |
| Staff COVID-19 vaccination coverage | 4.9% |
8.2%
3.3 pts worse
|
Numerator 5 · Denominator 102 |
| Staff flu vaccination coverage | 73.79% |
42%
31.8 pts better
|
Numerator 76 · Denominator 103 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 33 · Denominator 55 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 43 · Denominator 43 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 14.63% |
25.2%
10.6 pts worse
|
Numerator 6 · Denominator 41 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.3
0.5 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.2
1.7 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.9%
7.7 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 | 7.5% |
2.3%
5.2 pts worse
|
3.3%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.6% · Q2 8.7% · Q3 6.2% · Q4 7.6% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.9% |
21.4%
10.5 pts better
|
11.4%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 9.3% · Q3 13.2% · Q4 12.5% · 4Q avg 10.9% |
| Percentage of long-stay residents who lose too much weight | 13.5% |
5.7%
7.8 pts worse
|
5.4%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.0% · Q2 13.6% · Q3 8.3% · Q4 19.6% · 4Q avg 13.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 40.2% |
16.1%
24.1 pts worse
|
19.6%
20.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.8% · Q2 40.3% · Q3 42.2% · Q4 43.8% · 4Q avg 40.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 36.8% |
15.3%
21.5 pts worse
|
16.7%
20.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 44.2% · Q3 35.8% · Q4 25.9% · 4Q avg 36.8% · 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 | 24.9% |
26.6%
1.7 pts better
|
16.3%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 33.6% · Q3 23.0% · Q4 28.3% · 4Q avg 24.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 35.4% |
22.9%
12.5 pts worse
|
14.9%
20.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.5% · Q2 41.4% · Q3 23.7% · Q4 31.6% · 4Q avg 35.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.7%
0.3 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
1.5%
2.8 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 10.8% · Q3 1.6% · Q4 1.5% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.0% |
25.4%
6.4 pts better
|
19.8%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 14.4% · Q3 22.6% · Q4 14.3% · 4Q avg 19.0% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
6.3%
1.1 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 8.7% · Q3 4.0% · Q4 4.0% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
78.4%
18.3 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.6% · Q3 96.4% · Q4 93.8% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.8% |
9.9%
1.1 pts better
|
12.0%
3.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.8% · Observed 9.7% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.6% |
1.3%
5.3 pts worse
|
1.6%
5 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
80.6%
12.9 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.9% |
21.2%
8.3 pts better
|
23.9%
11 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 14.5% · Expected 26.9% · Used in QM five-star |
Survey summary
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Top issue: Quality of Life and Care (5 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-14
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-14
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-12-13
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 2018-06-23
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2018-06-23
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-06-27
Inspection history
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 2025-10-31
Health
Provide and implement an infection prevention and control program.
Corrected 2025-10-31
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 2025-03-28
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-03-28
Health
Respond appropriately to all alleged violations.
Corrected 2025-03-28
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-28
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 2025-03-28
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 2025-03-28
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-03-28
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-03-28
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-28
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-28
Health
Keep all essential equipment working safely.
Corrected 2025-03-28
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2019-12-31
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 2019-12-31
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2019-12-31
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2019-12-31
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-12-31
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-12-31
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 2019-12-31
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 2019-12-31
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 2019-12-31
Health
Provide or obtain dental services for each resident.
Corrected 2019-12-31
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-12-31
Health
Post nurse staffing information every day.
Corrected 2019-12-31
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-06-18
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-06-18
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 2018-06-18
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-06-18
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 2018-06-18
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-06-18
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-06-18
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 2018-06-18
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2018-06-18
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2018-06-18
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2018-06-18
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2018-06-18
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 2018-06-18
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 2018-06-18
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2018-06-18
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-06-18
Health
Keep all essential equipment working safely.
Corrected 2018-06-18
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2018-06-18
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2018-06-18
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 2018-06-18
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
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