Cycle 1
Health 2025-11-21 · Fire 2025-11-21
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Baltimore, MD
Transitional Care Services At Mercy Medical Center
5-star overall rating with 5-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
301 Saint Paul Place, Baltimore, MD
(410) 332-9287
Overall
5 / 5
CMS overall stars
Health inspections
5 / 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
35
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
1996-04-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
2.78
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
1.34
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.57
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
6.69
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
4.12
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
6.03
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
2.25
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
2.82
CMS adjusted RN staffing hours
Adjusted total hours
6.79
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Value-based purchasing
Program rank
113
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
84.57
Composite VBP score used to determine payment impact.
Payment multiplier
1.0266
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.37
Baseline 18.93% · Performance 18.94% · Measure score 5.37 · Achievement 5.37 · Improvement 0
Healthcare-associated infections
10
Baseline 3.86% · Performance 4.77% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
10
Baseline 55.88% · Performance 20.51% · Measure score 10 · Achievement 10 · Improvement 9
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 | 9.49% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 444 · Observed rate 6.76% · Lower 95% interval 6.97% |
| Discharge to community | 66.21% |
50.57%
15.6 pts better
|
Better than the National Rate · Eligible stays 401 · Observed rate 74.56% · Lower 95% interval 63.74% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 231 · Denominator 231 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 231 |
| Discharge self-care score | 37.77% |
53.69%
15.9 pts worse
|
Numerator 71 · Denominator 188 |
| Discharge mobility score | 36.7% |
50.94%
14.2 pts worse
|
Numerator 69 · Denominator 188 |
| Pressure ulcers or injuries, new or worsened | 1.73% |
2.29%
0.6 pts better
|
Numerator 4 · Denominator 231 · Adjusted rate 3.02% |
| Healthcare-associated infections requiring hospitalization | 4.77% |
7.12%
2.4 pts better
|
No Different than the National Rate · Eligible stays 231 · Observed rate 1.3% · Lower 95% interval 2.3% |
| Staff COVID-19 vaccination coverage | 25% |
8.2%
16.8 pts better
|
Numerator 14 · Denominator 56 |
| Staff flu vaccination coverage | 91.11% |
42%
49.1 pts better
|
Numerator 41 · Denominator 45 |
| Discharge function score | 39.36% |
56.45%
17.1 pts worse
|
Numerator 74 · Denominator 188 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 149 · Denominator 149 |
| Transfer of health information to patient | 98.72% |
96.28%
2.4 pts better
|
Numerator 77 · Denominator 78 |
| Resident COVID-19 vaccinations up to date | 6.36% |
25.2%
18.8 pts worse
|
Numerator 7 · Denominator 110 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
78.4%
21.6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.4% |
9.9%
5.5 pts better
|
12.0%
7.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.4% · Observed 4.3% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.3%
0.1 pts worse
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.8% · Q3 1.3% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.5% |
80.6%
16.9 pts better
|
79.7%
17.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.2% |
21.2%
4 pts worse
|
23.9%
1.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.2% · Observed 21.0% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-02 · Fire 2024-04-02
13 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-05-08 · Fire 2019-05-08
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-11-21
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2026-01-23
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-21
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 2025-12-11
D · Potential for more than minimal harm
2025-11-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-11-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-12-11
D · Potential for more than minimal harm
2025-11-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-12-11
E · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-02
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
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 2024-05-17
D · Potential for more than minimal harm
2024-04-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-04-02
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-05-17
D · Potential for more than minimal harm
2019-05-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2019-06-21
Penalties and ownership
What sits behind the stars
Ownership
Mercy Health Services Inc
5% Or Greater Indirect Ownership Interest · Organization
Mercy Medical Center Inc
5% Or Greater Direct Ownership Interest · Organization
Chase, Michele
Operational/Managerial Control · Individual
Deibel, Justin
Corporate Officer · Individual
Limpuangthip, Andrea
Operational/Managerial Control · Individual
Schwarzmann, Jennifer
Corporate Director · Individual
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