11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Sykesville, MD
4-star overall rating with 3-star inspections with 11 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
7200 Third Avenue, Sykesville, MD
(410) 795-8800
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
79
Certified beds
Average residents
41
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Acts Retirement-Life Communities
Operator or chain grouping
Approved since
1981-01-05
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
26 facilities
Chain averages 5 overall / 4 health / 5 staffing / 5 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
1.39
Registered nurse staffing · state 0.81 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.19
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
4.22
All reported nurse hours · state 3.87 · national 3.89
Licensed hours
2.03
RN + LPN hours · state 1.72 · national 1.54
Weekend hours
3.87
Weekend nurse staffing · state 3.46 · national 3.43
Weekend RN hours
1.14
Weekend registered nurse coverage · state 0.61 · national 0.47
Physical therapist
0.27
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.55
CMS adjusted RN staffing hours
Adjusted total hours
4.73
CMS adjusted total nurse staffing hours
Case-mix index
1.22
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 40% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 41% · national 46%
SNF VBP
Program rank
587
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
66.94
Composite VBP score used to determine payment impact.
Payment multiplier
1.0206
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
6.53
Baseline 21.43% · Performance 18.40% · Measure score 6.53 · Achievement 6.53 · Improvement 6.37
Healthcare-associated infections
7.14
Baseline 6.06% · Performance 5.70% · Measure score 7.14 · Achievement 7.14 · Improvement 2.89
Total nurse turnover
7.11
Baseline 38.33% · Performance 34.62% · Measure score 7.11 · Achievement 7.11 · Improvement 2.26
Adjusted total nurse staffing
5.99
Baseline 4.68 hours · Performance 4.78 hours · Measure score 5.99 · Achievement 5.99 · Improvement 0.40
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.08% |
10.72%
1.4 pts worse
|
No Different than the National Rate · Eligible stays 100 · Observed rate 13% · Lower 95% interval 7.47% |
| Discharge to community | 68.35% |
50.57%
17.8 pts better
|
Better than the National Rate · Eligible stays 79 · Observed rate 69.62% · Lower 95% interval 57.63% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 61 · Denominator 61 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 61 |
| Discharge self-care score | 71.15% |
53.69%
17.5 pts better
|
Numerator 37 · Denominator 52 |
| Discharge mobility score | 44.23% |
50.94%
6.7 pts worse
|
Numerator 23 · Denominator 52 |
| Pressure ulcers or injuries, new or worsened | 1.64% |
2.29%
0.7 pts better
|
Numerator 1 · Denominator 61 · Adjusted rate 1.68% |
| Healthcare-associated infections requiring hospitalization | 5.7% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 54 · Observed rate 0% · Lower 95% interval 2.82% |
| Staff COVID-19 vaccination coverage | 1.87% |
8.2%
6.3 pts worse
|
Numerator 2 · Denominator 107 |
| Staff flu vaccination coverage | 89.93% |
42%
47.9 pts better
|
Numerator 134 · Denominator 149 |
| Discharge function score | 59.62% |
56.45%
3.2 pts better
|
Numerator 31 · Denominator 52 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 31 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 31.43% |
25.2%
6.2 pts better
|
Numerator 11 · Denominator 35 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
1.3
2 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.5 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.2 · Expected 1.3 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 83.9% |
91.9%
8 pts worse
|
93.4%
9.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 82.1% · Q2 85.7% · Q3 86.2% · Q4 81.8% · 4Q avg 83.9% |
| 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 | 2.5% |
2.3%
0.2 pts worse
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 6.1% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
21.4%
21.4 pts better
|
11.4%
11.4 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 who lose too much weight | 5.0% |
5.7%
0.7 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 8.0% · Q4 10.7% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.3% |
16.1%
2.2 pts worse
|
19.6%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 16.7% · Q3 23.1% · Q4 16.7% · 4Q avg 18.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.4% |
15.3%
12.9 pts better
|
16.7%
14.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · Q4 4.0% · 4Q avg 2.4% · 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 | 20.1% |
26.6%
6.5 pts better
|
16.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.6% |
22.9%
2.3 pts better
|
14.9%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 17.4% · Q3 23.1% · Q4 16.7% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.8% |
0.7%
3.1 pts worse
|
1.0%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 6.2% · Q4 5.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.6% |
1.5%
1.1 pts worse
|
1.7%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 3.6% · Q4 3.2% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.5% |
25.4%
5.9 pts better
|
19.8%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.2% · Q2 29.7% · Q3 20.1% · Q4 8.2% · 4Q avg 19.5% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
6.3%
3 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 7.0% · Q3 3.0% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 78.3% |
78.4%
0.1 pts worse
|
81.7%
3.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 86.4% · Q2 77.5% · Q3 72.5% · Q4 76.2% · 4Q avg 78.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.4% |
9.9%
3.5 pts worse
|
12.0%
1.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.4% · Observed 12.1% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.3%
0.4 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.8% |
80.6%
7.2 pts better
|
79.7%
8.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.8% |
21.2%
3.6 pts worse
|
23.9%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.8% · Observed 20.7% · Expected 19.8% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Top issue: Nursing and Physician Services (3 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-10-01
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-10-01
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2025-10-01
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-10-01
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-08
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-07-08
Fire Safety
Construct fire resistant interior walls.
Corrected 2022-07-08
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2022-07-08
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-12-31
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2018-12-31
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2019-01-25
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2019-01-25
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2018-12-31
Inspection history
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2025-09-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-25
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 2025-09-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-25
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-09-25
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-09-25
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-25
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-25
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 2025-09-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-25
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 2025-09-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-07-01
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-01
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-07-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-07-27
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-07-01
Health
Respond appropriately to all alleged violations.
Corrected 2022-07-01
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-01
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 2018-12-21
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2018-12-21
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2018-12-21
Health
Ensure each resident receives an accurate assessment.
Corrected 2018-12-21
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2018-12-21
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2018-12-21
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2018-12-21
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 2018-12-21
Health
Observe each nurse aide's job performance and give regular training.
Corrected 2018-12-21
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2018-12-21
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 2018-12-21
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2018-12-21
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2018-12-21
Health
Provide and implement an infection prevention and control program.
Corrected 2018-12-21
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Mortgage Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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