| General |
| City |
| Frederick |
Pikesville |
| State attribute explanation |
| Md |
Md |
| Street |
| 700 Toll House Avenue |
7 Sudbrook Lane |
| Zip Code |
| 21,701 |
21,208 |
| Phone |
| 3,016,635,181 |
4,104,868,771 |
|
Overall Star Rating |
| 3 |
5 |
|
Health Inspections Star Rating |
| 2 |
4 |
|
Nurse Staffing Star Rating |
| 4 |
2 |
|
Quality Measures Star Rating |
| 4 |
5 |
|
RN Only Star Rating |
| 4 |
3 |
|
Number of Certified Beds |
| 143 |
140 |
|
Total Number of Residents |
| 90 |
133 |
|
Percent of Occupied Beds |
| 63 % |
95 % |
| Health Survey Date |
| 9/16/2011 |
8/15/2011 |
| Fire Survey Date |
| 7/8/2011 |
8/15/2011 |
| Sprinkler Status |
| Partially Sprinklered |
Partially Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| For Profit - Corporation |
For Profit - Corporation |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| Yes |
Yes |
| Resident and Family Councils |
| Both |
Both |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| Yes |
Yes |
| Special Focus Facility? |
| No |
No |
| Civil Money Penalty Count |
| 75.2 |
75.2 |
| Total Enforcement Actions Count |
| 75.2 |
75.2 |
| # of deficiencies |
| 13 |
10 |
|
| Staff Information |
| Number of Residents |
| 90 |
133 |
| Number of RN Hours Per Resident Per Day |
| 0.88 |
0.5 - 2.0 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.84 |
0.73 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.72 |
1.23 |
| Number of CNA Hours Per Resident Per Day |
| 0.03 |
0.09 |
| Number Therapy Hours Per Resident Per Day |
| 0.03 |
0.09 |
| Environmental Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure There Is A Pest Control Program To Prevent/deal With Mice, Insects, Or Other Pests.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
Scope: Manylevel Of Harm: 1deficiency: Be Designed, Built, Equipped, Or Well Kept To Protect The Health And Safety Of Residents, Workers, And The Public.survey Date: 06/26/2012date Of Correction: 07/19/2012 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide At Least One Room Set Aside To Use As A Resident Dining Room And For Activities, That Is A Good Size, With Good Lighting, Air Flow And Furniture.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
Scope: Manylevel Of Harm: 1deficiency: Provide Housekeeping And Maintenance Services.survey Date: 06/26/2012date Of Correction: 07/19/2012 |
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: Keep All Essential Equipment Working Safely.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
Scope: Fewlevel Of Harm: 3deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 09/10/2010date Of Correction: 09/10/2010 |
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 2deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
|
| Deficiency #5 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Housekeeping And Maintenance Services.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
|
| Resident Rights Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 1deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.survey Date: 05/01/2009date Of Correction: 05/16/2009 |
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 07/12/2011date Of Correction: 08/26/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Provide Routine And 24-hour Emergency Dental Care For Each Resident.survey Date: 09/10/2010date Of Correction: 10/27/2010 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 07/12/2011date Of Correction: 08/26/2011 |
|
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
|
| Resident Assessment Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
Scope: Fewlevel Of Harm: 2deficiency: Make Sure That A Doctor Approves A Resident's Admission In Writing And That Each Resident Remains Under The Care Of A Doctor.survey Date: 09/10/2010date Of Correction: 10/27/2010 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
|
| Administration Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
|
| Deficiency #2 |
| Scope: Somelevel Of Harm: 2deficiency: Operate And Provide Services According To Federal, State, And Local Laws And Professional Standards.survey Date: 01/07/2010date Of Correction: 01/25/2010 |
|
| Pharmacy Service Deficiencies |
| Deficiency #1 |
|
Scope: Manylevel Of Harm: 1deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.survey Date: 06/26/2012date Of Correction: 07/19/2012 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: At Least Once A Month, Have A Licensed Pharmacist Review Each Resident's Medication(s) And Report Any Irregularities To The Attending Doctor.survey Date: 09/10/2010date Of Correction: 10/27/2010 |
| Deficiency #3 |
|
Scope: Fewlevel Of Harm: 2deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.survey Date: 09/10/2010date Of Correction: 10/27/2010 |
| Nutrition and Dietary Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.survey Date: 08/31/2010date Of Correction: 10/21/2010 |
Scope: Manylevel Of Harm: 1deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.survey Date: 06/26/2012date Of Correction: 07/19/2012 |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 6.4 % |
21.2:1 |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 75.2 % |
2.20 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 7.5 % |
1.3 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 5 % |
10.3:1 |
| Percent of long-stay residents who lose too much weight |
| 11.4 % |
11.4 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
|
60 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 2.9 % |
4.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 6.6 % |
3.8 % |
| Percent of long-stay residents who have depressive symptoms |
| 5.8 % |
1.9 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 29.8 % |
16.5 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 66.9 % |
67.3 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 83.3 % |
58.8 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 |
4.7 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 6.4 % |
2.8 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 6.4 % |
23 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 75.2 % |
1.9 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 8.3 % |
2.9 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 4.4 % |
9.8 % |
| Percent of long-stay residents who lose too much weight |
| 5.8 % |
9.2 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 21.3 % |
52.1 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 4 % |
3.8 % |
| Percent of long-stay residents with a urinary tract infection |
| 2.9 % |
3.1 % |
| Percent of long-stay residents who have depressive symptoms |
| 5.7 % |
3.7 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 5.4 % |
2.4 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 25 % |
15.2 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 73.9 % |
76.3 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 84 % |
63.9 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 33.1 % |
8.7 % |