Cycle 1
Health 2024-07-22 · Fire 2024-07-22
7 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
5 fire-safety deficiencies
Top issue: Emergency Preparedness (2 deficiencies)
Baltimore, MD
North Oaks Communities
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
725 Mount Wilson Lane, Baltimore, MD
(410) 602-0302
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
37
Certified beds
Average residents
22
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1991-05-16
CMS approved date
Coverage
Medicare
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
1.61
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.32
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.03
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.96
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.93
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.69
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
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
2.01
CMS adjusted RN staffing hours
Adjusted total hours
4.95
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 41% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.39% |
10.72%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 21.05% · Lower 95% interval 7.9% |
| Discharge to community | 22.66% |
50.57%
27.9 pts worse
|
Worse than the National Rate · Eligible stays 28 · Observed rate 0% · Lower 95% interval 13.32% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 15 · 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 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 5.41% |
8.2%
2.8 pts worse
|
Numerator 4 · Denominator 74 |
| Staff flu vaccination coverage | 98.82% |
42%
56.8 pts better
|
Numerator 84 · Denominator 85 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.3
0.4 pts worse
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.0 · Expected 1.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.2
0.8 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.4 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 71.2% |
91.9%
20.7 pts worse
|
93.4%
22.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 71.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.0% |
2.3%
8.7 pts worse
|
3.3%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
21.4%
20 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 2.3% |
5.7%
3.4 pts better
|
5.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 26.0% |
16.1%
9.9 pts worse
|
19.6%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.1% |
15.3%
6.2 pts better
|
16.7%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.1% · 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 | 40.1% |
26.6%
13.5 pts worse
|
16.3%
23.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 40.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 34.0% |
22.9%
11.1 pts worse
|
14.9%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.0% · 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 · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.2% |
25.4%
12.8 pts worse
|
19.8%
18.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.2% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
6.3%
5.1 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 50.7% |
78.4%
27.7 pts worse
|
81.7%
31 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q2 60.0% · 4Q avg 50.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.5% |
9.9%
14.6 pts worse
|
12.0%
12.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.5% · Observed 20.0% · Expected 9.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
1.3%
3.6 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.0% |
80.6%
0.4 pts better
|
79.7%
1.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 7.1% |
21.2%
14.1 pts better
|
23.9%
16.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 5.0% · Expected 16.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-10-15 · Fire 2019-10-15
19 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2018-07-10 · Fire 2018-07-10
14 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 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
2024-07-22
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-07-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-07-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-03
D · Potential for more than minimal harm
2024-07-22
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 2024-09-03
D · Potential for more than minimal harm
2024-07-22
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-03
D · Potential for more than minimal harm
2019-10-15
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 2019-11-18
D · Potential for more than minimal harm
2019-10-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2019-10-28
D · Potential for more than minimal harm
2019-10-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-10-15
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 2019-11-08
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-20
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 2026-01-10
D · Potential for more than minimal harm
2025-11-20
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2025-11-24
D · Potential for more than minimal harm
2025-11-20
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2026-01-16
F · Potential for more than minimal harm
2024-07-22
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 2024-08-30
D · Potential for more than minimal harm
2024-07-22
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 2024-08-30
D · Potential for more than minimal harm
2024-07-22
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-08-30
D · Potential for more than minimal harm
2024-07-22
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 2024-08-30
F · Potential for more than minimal harm
2019-10-15
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 2019-12-19
E · Potential for more than minimal harm
2019-10-15
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 2019-12-19
D · Potential for more than minimal harm
2019-10-15
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-10-15
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-10-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-10-15
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 2019-12-19
D · Potential for more than minimal harm
2019-10-15
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 2019-12-19
D · Potential for more than minimal harm
2019-10-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-10-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-10-15
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 2019-12-19
D · Potential for more than minimal harm
2019-10-15
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 2019-12-19
D · Potential for more than minimal harm
2019-10-15
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-10-15
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-10-15
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 2019-12-19
D · Potential for more than minimal harm
2019-10-15
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-12-19
D · Potential for more than minimal harm
2019-10-15
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 2019-12-19
D · Potential for more than minimal harm
2019-10-15
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 2019-12-19
C · Minimal harm
2019-10-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2019-12-19
B · Minimal harm
2019-10-15
F559 · Resident Rights Deficiencies
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 2019-12-19
F · Potential for more than minimal harm
2018-07-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-08-24
E · Potential for more than minimal harm
2018-07-10
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 2018-08-24
D · Potential for more than minimal harm
2018-07-10
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 2018-08-24
D · Potential for more than minimal harm
2018-07-10
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 2018-08-24
D · Potential for more than minimal harm
2018-07-10
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 2018-08-24
D · Potential for more than minimal harm
2018-07-10
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-07-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-07-10
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 2018-08-24
D · Potential for more than minimal harm
2018-07-10
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-07-10
F727 · Nursing and Physician Services Deficiencies
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 2018-08-24
D · Potential for more than minimal harm
2018-07-10
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2018-08-24
D · Potential for more than minimal harm
2018-07-10
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 2018-08-24
C · Minimal harm
2018-07-10
F608 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Corrected 2018-08-24
C · Minimal harm
2018-07-10
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2018-08-24
Penalties and ownership
What sits behind the stars
Ownership
Biderman, Michael
5% Or Greater Direct Ownership Interest · Individual
Biderman, Michael
Operational/Managerial Control · Individual
Bsd 26 Holdings LLC
5% Or Greater Direct Ownership Interest · Organization
Ike Akiko
5% Or Greater Direct Ownership Interest · Organization
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