Staffing
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.38 hours per resident day in 2026Q1, calculated from CMS PBJ records.
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AUTUMN LAKE HEALTHCARE AT CATONSVILLE has 136 certified beds in CATONSVILLE, Maryland. The CMS overall rating is 2 of 5, compared with the Maryland average of 3.1. The CMS health inspection rating is 1 of 5, compared with the Maryland average of 2.8. The CMS staffing rating is 2 of 5. The latest standard health survey on Aug 18, 2025 lists 16 deficiencies, compared with the Maryland average of 12.1. Total nurse staffing is 3.38 hours per resident day in 2026Q1, compared with the Maryland average of 3.89.
CMS nursing home
CATONSVILLE, MD
Independent research from official CMS public records. No paid ranking. No Trust Hub quality score.
Research this nursing home using CMS and federal public records. CMS Certification Number 215097.
At a glance
2 of 5
1 of 5
2 of 5
5 of 5
CMS has published 1 ownership-change record for this provider.
These are CMS star ratings, not Trust Hub ratings. Missing evidence is shown as not reported, not as zero.
Quality & care evidence
Staffing, inspections, and fire safety are separate CMS evidence families below.
Ownership & management
Current ownership uses CURRENT OWNED_BY evidence only. UNKNOWN is not a former owner.
These relationships were observed in an older snapshot. UNKNOWN does not mean former owner, previous owner, or that ownership ended.
Ownership change history
CMS publishes Change of Ownership records for this nursing home.
CMS records show an ownership change effective 2021-05-01.
These are CMS transaction records. They are not a Trust Hub quality, stability, or sale judgment.
Source freshness
Profile generated 2026-11-03. That timestamp is not CMS evidence freshness.
Methodology
CMS overview
No proprietary TrustHub score. These ratings are published separately by CMS. How CMS ratings and facility records are read
Facility information
CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.
CMS designations
This CMS Certification Number appears in the latest CMS Nursing Home Provider Information extract of currently listed nursing homes.
CMS does not currently identify this nursing home as a Special Focus Facility or candidate in the loaded Provider Information extract.
CMS field value: (blank). Observed Aug 1, 2026.
CMS does not currently apply its abuse-icon designation to this facility in the loaded Provider Information extract.
CMS field value: N. Observed Aug 1, 2026.
Enrollment identity
These identifiers come from CMS SNF enrollment records linked to this CCN. They are not a substitute for the CMS Certification Number.
MDS quality measures
These MDS quality measures are individual CMS-published scores. They are not the CMS quality-measure star rating.
MDS source release 2026-08-01.
Fire-safety citations
These are fire-safety citations, not health deficiencies and not a count of fires.
Decision guide
Factual evidence to examine before you decide. These summaries are not a score or recommendation.
CMS publishes a 2-star staffing rating for this facility.
RN staffing was 0.38 hours per resident day in 2026Q1, calculated from CMS PBJ records.
View staffing evidenceThe latest standard inspection on Aug 18, 2025 cited 16 deficiencies.
View inspection evidenceCMS-published records list 25 ownership or control parties.
CMS records show an ownership change effective May 2021.
View ownership evidenceCMS groups this facility with a chain covering 60 facilities across 5 states or territories.
View chain evidenceOwnership & operation
Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.
SeniorTrustHub found evidence connecting this facility to:
12 currently connected nursing homes share this CMS organization identity with A&R STERN FAMILY MD1 HOLDINGS LLC.
Ownership
These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across MD.
Organization · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 23, 2022
Organization · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Other facilities connected through this exact CMS organization identity: 0 across MD.
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 7, 2023
Individual · CORPORATE OFFICER
Association date reported to CMS: May 1, 2021
Individual · INDIRECT OWNERSHIP INTEREST
Association date reported to CMS: May 1, 2021
Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Mar 27, 2025
Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF
Association date reported to CMS: Mar 27, 2025
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 23, 2022
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 7, 2023
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST
Published ownership percentage: 100%
Association date reported to CMS: May 1, 2021
CMS classifications: Parent company, Holding company
Other facilities connected through this exact CMS organization identity: 0 across MD.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 74.15%
Association date reported to CMS: May 1, 2021
CMS classifications: Holding company
Other facilities connected through this exact CMS organization identity: 11 across MD.
Organization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 24.85%
Association date reported to CMS: May 1, 2021
Other facilities connected through this exact CMS organization identity: 11 across MD.
Organization · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Other facilities connected through this exact CMS organization identity: 40 across CT, MD, NJ, WI, WV.
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 23, 2022
Organization · ADP OF THE SNF
Association date reported to CMS: May 1, 2021
Other facilities connected through this exact CMS organization identity: 57 across CT, FL, MD, NC, NJ, PA, RI, TN, VT, WI, WV.
Individual · ADP OF THE SNF
Association date reported to CMS: Jul 7, 2023
Individual · CORPORATE OFFICER
Association date reported to CMS: May 1, 2021
Individual · INDIRECT OWNERSHIP INTEREST
Published ownership percentage: 1%
Association date reported to CMS: May 1, 2021
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 23, 2022
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: Jul 7, 2023
Individual · OPERATIONAL/MANAGERIAL CONTROL
Association date reported to CMS: May 1, 2021
Organization · Medicare-enrolled legal organization
Other facilities connected through this exact CMS organization identity: 0 across MD.
Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.
Chain context
Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 56 is a grouping identifier, not a legal organization.
| Month | Facilities | Overall rating | Staffing rating |
|---|---|---|---|
| Wed Jul | 60 | 2.9 | 2.4 |
| Mon Jun | 60 | 3 | 2.5 |
| Fri May | 60 | 3 | 2.5 |
| Wed Apr | 60 | 3 | 2.5 |
| Sun Mar | 60 | 2.8 | 2.5 |
| Sun Feb | 60 | 2.8 | 2.5 |
Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.
View official CMS sourceInspections & deficiencies
Scope and severity terms below are CMS classifications. They are not a TrustHub score.
Respond appropriately to all alleged violations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 24, 2026)
Dispose of garbage and refuse properly.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 24, 2026)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jul 24, 2026)
No health-deficiency rows were deterministically linked to this inspection.
Ensure each resident receives an accurate assessment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Provide safe, appropriate pain management for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
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.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Ensure services provided by the nursing facility meet professional standards of quality.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Post nurse staffing information every day.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
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.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Dispose of garbage and refuse properly.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Provide and implement an infection prevention and control program.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Keep all essential equipment working safely.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
Make sure that a working call system is available in each resident's bathroom and bathing area.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Oct 22, 2025)
No health-deficiency rows were deterministically linked to this inspection.
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Give residents a notice of rights, rules, services and charges.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
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.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Respond appropriately to all alleged violations.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
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.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Post nurse staffing information every day.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Ensure medication error rates are not 5 percent or greater.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
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.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
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.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
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.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (May 8, 2023)
No health-deficiency rows were deterministically linked to this inspection.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Reasonably accommodate the needs and preferences of each resident.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
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.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Prepare residents for a safe transfer or discharge from the nursing home.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Ensure each resident receives an accurate assessment.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Honor each resident's preferences, choices, values and beliefs.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Provide care and assistance to perform activities of daily living for any resident who is unable.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Provide safe, appropriate pain management for a resident who requires such services.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Observe each nurse aide's job performance and give regular training.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Ensure that residents are free from significant medication errors.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
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.
CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Provide and implement an infection prevention and control program.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Keep all essential equipment working safely.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Have enough backup water supply for essential areas of the nursing home.
CMS scope/severity F: Widespread; No actual harm with potential for more than minimal harm that is not immediate jeopardy.
Correction status: Deficient, Provider has date of correction (Jan 31, 2019)
Penalties & enforcement
No penalty records were found for this provider in the currently loaded CMS Penalties dataset.
Questions to ask
Facility history
6 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.
16 deficiencies were recorded.
CMS · Recorded event date · View related evidence
4 deficiencies were recorded.
CMS · Recorded event date · View related evidence
No linked health-deficiency findings were recorded for this survey.
CMS · Recorded event date · View related evidence
27 deficiencies were recorded.
CMS · Recorded event date · View related evidence
An ownership change was recorded. New organization: 16 FUSTING OPCO LLC.
16 FUSTING AVENUE OPERATIONS LLC → 16 FUSTING OPCO LLC
CMS · Recorded event date · View related evidence
29 deficiencies were recorded.
CMS · Recorded event date · View related evidence
Staffing
CMS staffing rating: 2 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).
| Measure | Monday–Friday | Saturday–Sunday |
|---|---|---|
| Total nursing | 3.49 | 3.115 |
| RN categories | 0.421 | 0.294 |
Contract staff accounted for 19.9% of reported nursing hours included in this quarter calculation.
Reported RN-category hours per resident day were 0.059 lower than the prior loaded quarter.
Solid bar: Total nursing · Outlined bar: RN categories
| Quarter | Total nursing | RN categories | LPN/LVN | CNA | Contract share | Days |
|---|---|---|---|---|---|---|
| 2025Q2 | 3.492 | 0.471 | 0.946 | 2.075 | 23.5% | 91 |
| 2025Q3 | 3.539 | 0.472 | 1.007 | 2.06 | 18.3% | 92 |
| 2025Q4 | 3.411 | 0.444 | 0.964 | 2.003 | 15.6% | 92 |
| 2026Q1 | 3.381 | 0.384 | 1.027 | 1.97 | 19.9% | 90 |
Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.
View official CMS PBJ sourceWhat we can verify today
These measures come from the current successfully ingested CMS Nursing Home Provider Information release.
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