30 health deficiencies
Top issue: Resident Rights (9 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Mitchellville, MD
2-star overall rating with 2-star inspections with 30 recent health deficiencies with 21 fire-safety deficiencies in the latest cycle
3800 Lottsford Vista Road, Mitchellville, MD
(301) 459-4700
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Beds
107
Certified beds
Average residents
77
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
2006-11-20
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
0.68
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.83
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
1.57
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.06
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
0.61
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.67
CMS adjusted RN staffing hours
Adjusted total hours
3.34
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
65%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
3,800
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9956
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
4.62
Baseline 19.47% · Performance 19.29% · Measure score 4.62 · Achievement 4.62 · Improvement 0.24
Healthcare-associated infections
4.05
Baseline 7.92% · Performance 6.62% · Measure score 4.05 · Achievement 4.05 · Improvement 3.93
Total nurse turnover
7.42
Baseline 30.44% · Performance 33.33% · Measure score 7.42 · Achievement 7.42 · Improvement 0
Adjusted total nurse staffing
0.96
Baseline 3.33 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.65% |
10.72%
3.9 pts worse
|
Worse than the National Rate · Eligible stays 290 · Observed rate 15.86% · Lower 95% interval 11.44% |
| Discharge to community | 59.06% |
50.57%
8.5 pts better
|
Better than the National Rate · Eligible stays 207 · Observed rate 56.04% · Lower 95% interval 53.61% |
| Medicare spending per beneficiary | 0.86 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.17% |
95.27%
0.1 pts worse
|
Numerator 138 · Denominator 145 |
| Falls with major injury | 2.76% |
0.77%
2 pts worse
|
Numerator 4 · Denominator 145 |
| Discharge self-care score | 60.4% |
53.69%
6.7 pts better
|
Numerator 61 · Denominator 101 |
| Discharge mobility score | 41.58% |
50.94%
9.4 pts worse
|
Numerator 42 · Denominator 101 |
| Pressure ulcers or injuries, new or worsened | 5.52% |
2.29%
3.2 pts worse
|
Numerator 8 · Denominator 145 · Adjusted rate 4.31% |
| Healthcare-associated infections requiring hospitalization | 6.62% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 5.85% · Lower 95% interval 4.63% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 109 |
| Staff flu vaccination coverage | 85.95% |
42%
44 pts better
|
Numerator 104 · Denominator 121 |
| Discharge function score | 50.5% |
56.45%
6 pts worse
|
Numerator 51 · Denominator 101 |
| Transfer of health information to provider | 91.11% |
95.95%
4.8 pts worse
|
Numerator 41 · Denominator 45 |
| Transfer of health information to patient | 96.08% |
96.28%
0.2 pts worse
|
Numerator 49 · Denominator 51 |
| Resident COVID-19 vaccinations up to date | 5.63% |
25.2%
19.6 pts worse
|
Numerator 4 · Denominator 71 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.5 |
1.2
0.7 pts better
|
1.8
1.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.6% |
91.9%
1.7 pts better
|
93.4%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 94.5% · Q3 94.1% · Q4 86.6% · 4Q avg 93.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.1% |
96.6%
1.5 pts worse
|
95.5%
0.4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
2.3%
1.3 pts worse
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.1% · Q3 2.9% · Q4 1.5% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 35.6% |
21.4%
14.2 pts worse
|
11.4%
24.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 60.3% · Q2 44.6% · Q3 19.6% · Q4 12.1% · 4Q avg 35.6% |
| Percentage of long-stay residents who lose too much weight | 5.4% |
5.7%
0.3 pts better
|
5.4%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 5.9% · Q3 8.3% · Q4 3.2% · 4Q avg 5.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 4.5% |
16.1%
11.6 pts better
|
19.6%
15.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.2% · Q3 4.7% · Q4 4.8% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.3% |
15.3%
1 pts better
|
16.7%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.2% · Q2 16.3% · Q3 13.7% · Q4 14.0% · 4Q avg 14.3% · 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 | 43.8% |
26.6%
17.2 pts worse
|
16.3%
27.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 43.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.0% |
22.9%
8.1 pts worse
|
14.9%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 34.4% · Q3 38.9% · Q4 25.9% · 4Q avg 31.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.7%
0.1 pts worse
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 1.2% · Q3 0.9% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.5%
0.8 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.3% |
25.4%
10.1 pts better
|
19.8%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 19.9% · Q3 16.2% · Q4 14.0% · 4Q avg 15.3% |
| Percentage of long-stay residents with pressure ulcers | 6.7% |
6.3%
0.4 pts worse
|
5.1%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 5.5% · Q3 8.0% · Q4 7.7% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 73.1% |
78.4%
5.3 pts worse
|
81.7%
8.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 77.9% · Q2 75.0% · Q3 65.7% · Q4 71.7% · 4Q avg 73.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
9.9%
0.8 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 9.3% · Expected 11.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.4% |
1.3%
0.9 pts better
|
1.6%
1.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.5% |
80.6%
5.1 pts worse
|
79.7%
4.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.6% |
21.2%
1.4 pts worse
|
23.9%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.6% · Observed 23.7% · Expected 25.1% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (9 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (8 deficiencies)
Top issue: Pharmacy Service (1 deficiency)
14 fire-safety deficiencies
Top issue: Egress (4 deficiencies)
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-03-13
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-13
Fire Safety
Meet other general requirements.
Corrected 2025-03-13
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-13
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 2025-05-29
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-21
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-03-13
Fire Safety
Meet other general requirements that are deficient.
Corrected 2025-05-29
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-03-13
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-13
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-10-28
Fire Safety
Include a process for Emergency Preparedness collaboration.
Corrected 2024-09-04
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-09-04
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 2024-10-28
Fire Safety
Install proper backup exit lighting.
Corrected 2024-07-22
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-07-22
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 2024-07-22
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-28
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-07-22
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-10-28
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-28
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-10-28
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-07-22
Fire Safety
Have elevators that firefighters can control in the event of a fire.
Corrected 2024-07-22
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-07-22
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-10-28
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-28
Fire Safety
Have exits that are accessible at all times.
Corrected 2024-09-04
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-10-28
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-22
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-07-22
Fire Safety
Have exits that are accessible at all times.
Corrected 2019-07-15
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 2019-07-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-07-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-07-15
Inspection history
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2026-02-14
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-02-14
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 2026-02-14
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2026-02-14
Health
Respond appropriately to all alleged violations.
Corrected 2026-02-14
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2026-02-14
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-07-01
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 2024-07-01
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-07-01
Health
Respond appropriately to all alleged violations.
Corrected 2024-07-01
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-07-01
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 2024-07-01
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-07-01
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-07-01
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 2024-07-01
Health
Provide activities to meet all resident's needs.
Corrected 2024-07-01
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2024-07-01
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-07-01
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 2024-07-01
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-07-01
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-01
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-07-01
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-01
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-07-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-01
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 2024-07-01
Health
Provide or obtain dental services for each resident.
Corrected 2024-07-01
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-01
Health
Provide and implement an infection prevention and control program.
Corrected 2024-07-01
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-07-01
Health
Put firmly secured handrails on each side of hallways.
Corrected 2024-07-01
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2024-07-01
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 2018-01-22
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-01-22
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2018-01-22
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2018-01-22
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-01-22
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-01-22
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 2018-01-22
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2018-01-22
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2018-01-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2018-01-22
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-01-22
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 2018-01-22
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2018-01-22
Health
Provide and implement an infection prevention and control program.
Corrected 2018-01-22
Health
Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.
Corrected 2018-01-22
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
W-2 Managing Employee · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
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