Cycle 1
Health 2023-01-09 · Fire 2023-01-09
12 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Washington, DC
Sibley Mem Hosp Renaissance
5-star overall rating with 4-star inspections with $8,827 in total fines with 12 recent health deficiencies
5255 Loughboro Road Nw, Washington, DC
(202) 537-4000
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
45
Certified beds
Average residents
32
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1994-05-27
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
4.94
Registered nurse staffing · state 1.74 · national 0.68
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
1.94
Nurse aide staffing · state 2.55 · national 2.35
Total nurse hours
6.89
All reported nurse hours · state 4.85 · national 3.89
Licensed hours
4.94
RN + LPN hours · state 2.30 · national 1.54
Weekend hours
6.13
Weekend nurse staffing · state 4.35 · national 3.43
Weekend RN hours
4.07
Weekend registered nurse coverage · state 1.38 · national 0.47
Physical therapist
0.37
Reported PT staffing · state 0.12 · national 0.07
Adjusted RN hours
4.45
CMS adjusted RN staffing hours
Adjusted total hours
6.19
CMS adjusted total nurse staffing hours
Case-mix index
1.52
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 31% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 33% · national 46%
SNF VBP
Value-based purchasing
Program rank
776
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.92
Composite VBP score used to determine payment impact.
Payment multiplier
1.0185
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.71
Baseline 16.55% · Performance 20.64% · Measure score 1.71 · Achievement 1.71 · Improvement 0
Healthcare-associated infections
9.30
Baseline 5.98% · Performance 5.06% · Measure score 9.30 · Achievement 9.30 · Improvement 8.89
Total nurse turnover
8.17
Baseline 31.58% · Performance 30.30% · Measure score 8.17 · Achievement 8.17 · Improvement 1.40
Adjusted total nurse staffing
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.83% |
10.72%
0.9 pts better
|
No Different than the National Rate · Eligible stays 316 · Observed rate 8.23% · Lower 95% interval 7.42% |
| Discharge to community | 71.26% |
50.57%
20.7 pts better
|
Better than the National Rate · Eligible stays 335 · Observed rate 65.97% · Lower 95% interval 65.84% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 86.81% |
95.27%
8.5 pts worse
|
Numerator 204 · Denominator 235 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 235 |
| Discharge self-care score | 9.68% |
53.69%
44 pts worse
|
Numerator 18 · Denominator 186 |
| Discharge mobility score | 13.98% |
50.94%
37 pts worse
|
Numerator 26 · Denominator 186 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 235 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.06% |
7.12%
2.1 pts better
|
No Different than the National Rate · Eligible stays 210 · Observed rate 3.33% · Lower 95% interval 3.08% |
| Staff COVID-19 vaccination coverage | 5.26% |
8.2%
2.9 pts worse
|
Numerator 4 · Denominator 76 |
| Staff flu vaccination coverage | 100% |
42%
58 pts better
|
Numerator 54 · Denominator 54 |
| Discharge function score | 10.75% |
56.45%
45.7 pts worse
|
Numerator 20 · Denominator 186 |
| Transfer of health information to provider | 85.92% |
95.95%
10 pts worse
|
Numerator 177 · Denominator 206 |
| Transfer of health information to patient | 73.08% |
96.28%
23.2 pts worse
|
Numerator 19 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 42.19% |
25.2%
17 pts better
|
Numerator 54 · Denominator 128 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.9% |
66.1%
29.8 pts better
|
81.7%
14.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 94.2% · Q3 96.7% · Q4 99.4% · 4Q avg 95.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.4% |
7.2%
0.2 pts worse
|
12.0%
4.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.4% · Observed 7.0% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
0.7%
1 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.7% · Q3 2.4% · Q4 1.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
73.2%
26.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.5% |
18.1%
7.4 pts worse
|
23.9%
1.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.5% · Observed 25.2% · Expected 23.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-23 · Fire 2021-04-23
11 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2019-09-13 · Fire 2019-09-13
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2021-04-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-22
E · Potential for more than minimal harm
2021-04-23
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-22
F · Potential for more than minimal harm
2019-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-12
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-08-14
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-10-07
D · Potential for more than minimal harm
2024-08-14
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 2024-10-07
D · Potential for more than minimal harm
2024-08-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-10-07
J · Immediate jeopardy
2024-02-06
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-06
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 2024-03-04
E · Potential for more than minimal harm
2023-01-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-09
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 2023-03-10
D · Potential for more than minimal harm
2023-01-09
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 2023-03-10
D · Potential for more than minimal harm
2023-01-09
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-09
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 2023-03-10
D · Potential for more than minimal harm
2023-01-09
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-09
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 2023-03-10
D · Potential for more than minimal harm
2023-01-09
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 2023-03-10
D · Potential for more than minimal harm
2023-01-09
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 2023-03-10
D · Potential for more than minimal harm
2023-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-10
D · Potential for more than minimal harm
2023-01-09
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-03-10
G · Actual harm
2021-04-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-06-22
E · Potential for more than minimal harm
2021-04-23
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 2021-06-22
E · Potential for more than minimal harm
2021-04-23
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2021-06-22
D · Potential for more than minimal harm
2021-04-23
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2021-06-22
D · Potential for more than minimal harm
2021-04-23
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 2021-06-22
D · Potential for more than minimal harm
2021-04-23
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 2021-06-22
D · Potential for more than minimal harm
2021-04-23
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 2021-06-22
D · Potential for more than minimal harm
2021-04-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-22
E · Potential for more than minimal harm
2019-09-13
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2019-11-12
E · Potential for more than minimal harm
2019-09-13
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 2019-11-12
E · Potential for more than minimal harm
2019-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-13
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 2019-11-12
D · Potential for more than minimal harm
2019-09-13
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-09-13
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 2019-11-12
D · Potential for more than minimal harm
2019-09-13
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2019-11-12
Penalties and ownership
What sits behind the stars
$8,827
2024-02-06
Fine
Fine · fine $8,827
Fine
Ownership
Abele, Jennifer
Corporate Director · Individual
Ammerman, Joshua
Corporate Director · Individual
Argo, Archie
Corporate Director · Individual
Barron, Jessica
Operational/Managerial Control · Individual
Barton, William
Corporate Director · Individual
Bulen, James
Operational/Managerial Control · Individual
Carpenter, Carolyn
Corporate Director · Individual
Cecil, Guy
Corporate Director · Individual
Cernea, Andrei
Corporate Director · Individual
Crickenberger, Brian
Operational/Managerial Control · Individual
Cryer, Donna
Corporate Director · Individual
Duran, Mishaela
Corporate Director · Individual
Elyanow, Kimberly
Corporate Officer · Individual
Farr, Michael
Corporate Director · Individual
Hajj, Ahmad
Corporate Director · Individual
Harrington, Jenny
Corporate Director · Individual
Hendricks-Jackson, Laura
Corporate Officer · Individual
Hertz, Harry
Corporate Director · Individual
Horton, Karen
Corporate Director · Individual
Humphries, Fred
Corporate Director · Individual
Lewin, Cynthia
Corporate Director · Individual
Lewis, Joan
Corporate Director · Individual
Mallett, Robert
Corporate Director · Individual
Mancino, Peter
Corporate Officer · Individual
Marshall, Capricia
Corporate Director · Individual
Miller, Edward
Corporate Director · Individual
Miyamoto, Suzanne
Corporate Director · Individual
Morris, Richard
Corporate Director · Individual
Mullick, Anu
Corporate Director · Individual
Owens, Pamela
Corporate Officer · Individual
Parker, Charles
Corporate Director · Individual
Paul, Martin
Corporate Director · Individual
Pratt, Tiffany
Corporate Officer · Individual
Reinard, Chris
Corporate Officer · Individual
Schaefer, Thomas
Corporate Director · Individual
Shafa, Caroline
Corporate Officer · Individual
Silberman, Robert
Corporate Director · Individual
Sowers, Kevin
Corporate Officer · Individual
Strawbridge, Welsh
Corporate Director · Individual
The Johns Hopkins Health System Corporation
5% Or Greater Direct Ownership Interest · Organization
Wright, Pandit
Corporate Director · Individual
Zia, Hasan
Operational/Managerial Control · Individual
Zia, Hasan
Corporate Officer · Individual
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