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Little Sisters Of The Poor

601 Maiden Choice Lane, Baltimore, MD 21228 · For profit - Individual · 20 certified beds · (410) 744-9367 Medicare & Medicaid certified

Call the home — (410) 744-9367 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Mar 2023Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

This home’s record is mixed — some reassuring signs, some worth asking about.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (5/5)
  • lower-than-typical staff turnover (33% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure rating is low (1/5)

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

4/5
CMS overall
4 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 1 of 5

Location & what’s nearby

Urgent care / clinic
716 Maiden Choice Ln Ste 102 · (410) 337-4500 · Call to confirm hours
Pharmacy
715 Maiden Choice Ln · (410) 737-8820 · Call to confirm hours
Grocery
Giant0.4 mi
4622 Wilkens Ave
Park
55 Wade Ave · Typically dawn to dusk
Place of worship
715 Maiden Choice Ln · (443) 500-3266

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 1 of 5
Long-stay residentspeople who live here 1 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 4 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating4★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased31.8%20.4%15.4%worse
Long-stay residents who lose too much weight3.1%5.4%5.4%better
Long-stay residents with a catheter left in their bladder2.5%0.5%0.9%worse
Long-stay residents with a urinary tract infection1.6%1.5%2.0%better
Long-stay residents with depressive symptoms0.0%22.8%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury10.4%2.4%3.3%worse
Long-stay residents whose ability to walk worsened21.1%22.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication44.8%16.7%18.9%worse
Long-stay residents with pressure ulcers8.7%5.9%4.7%worse
Long-stay residents with worsening bladder/bowel control23.6%25.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table35.4%13.8%17.1%worse
Long-stay hospitalizations per 1,000 resident days2.711.331.67worse
Long-stay outpatient ER visits per 1,000 resident days0.841.201.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

0.47U.S. median 0.31
Therapy hours / resident / day
0.35hours / resident / day
Physical therapy
0.12hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.47 therapist hours per resident per day in 2026Q1 — more than 78% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 3% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

1.69
RN hours/ resident / day
1.42
LPN hours/ resident / day
4.14
Aide hours/ resident / day
7.25
Total nurse hours/ resident / day
1.40
RN hoursweekends
33.3%
Total nursing turnover
25.0%
RN turnover

How full it usually is: this home is certified for 20 beds and averages 16.8 residents a day — about 84% occupied, or roughly 3 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 7.25 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.69 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 4.14 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 6.42 hrs/resident/day on weekends vs 7.59 on weekdays — 15% thinner on weekends. RN hours go from 1.81 to 1.40 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 33% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

1
deficiencies at the latest standard inspection (2025-06-25)
22
at the previous standard inspection (2023-03-30)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

  • Potential for harm · D2025-06-25 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview with facility staff, it was determined that the facility failed to protect the dignity of a resident with urine bag. The deficient practice was found evident for 1 resident (Resident #11) out of 1 resident observed with urine bag during the facility's Medicare/Medicaid recertification survey. The findings include: An indwelling urinary catheter, often called a Foley catheter, is a flexible tube inserted into the bladder to drain urine when a person is unable to urinate on their own. It is typically held in place by a small balloon inflated with sterile water inside the bladder. A urine bag, also known as a drainage bag, is a medical device used to collect urine when a person cannot urinate on their own or needs a way to collect urine for medical testing. It's typically connected to a urinary catheter, which is a tube inserted into the bladder. Urine drains from the bladder through the catheter and into the bag. On 06/23/25 at 08:23 AM, during the initial tour of the facility, the surveyor observed that Resident #11 had a urinary bag which was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-03-30 · tag F0801 — widespread
    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.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interview it was determined the facility failed to have a full time certified dietary manager to oversee the operations in the dietary department. This was evident during a tour of the kitchen during the annual survey and had the potential to affect all residents. The findings include: On 3/22/23 at 9:03 AM a tour of the kitchen was conducted with the Director of Food Service, Staff #20. Staff #20 was asked if she was a certified dietary manager (CDM). Staff #20 stated, I have a pre CDM, but I still have to take the test. On 3/29/23 at 1:30 PM an interview was conducted with the Registered Dietician (RD). The RD stated she was only at the facility one day a week on Mondays. When asked if she supervised the kitchen operations she stated, I don't supervise in the kitchen. On 3/29/23 at 2:34 PM the Nursing Home Administrator was informed of the concern and failed to produce documentation that Staff #20 was a CDM.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2023-03-30 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on documentation review and interview, it was determined the facility failed to have a quality assurance policy that had written procedures for quality assurance activities. This was evident during the annual survey and had the potential to affect all residents. The findings include: On 3/30/23 at 1:52 PM an interview with was conducted with Licensed Practical Nurse (LPN) #3 who oversaw quality assurance activities and Staff #31. LPN #3 described the items that were reported on in quality assurance meetings. The quality assurance and performance improvement program policy was reviewed with LPN #3 and Staff #31. The policy was six pages and documented the purpose, organization, authority, responsibilities, methodology, problem assessment, confidentiality, and evaluation. The policy was an outline of what the facility planned to do and did not have a breakdown of the procedures to do the activities. The policy was missing the following: - procedures for data collection from staff, residents, and RP's (resident representatives) - procedures in the Problem Assessment section -…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-30 · tag F0622 — pattern
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to: 1) orient, prepare, and document a resident's preparation for a transfer to the hospital and 2) document that information was provided to the acute care facility when a resident was transferred there emergently. This was identified for 3 (Resident #9, #16, #4) of 3 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 3/23/23 at 9:17 AM an interview was conducted with Resident #9. Resident #9 was asked if h/she had been sent to the hospital recently. Resident #9 stated, yes, to rule out a vein blockage. On 3/24/23 at 8:27 AM a review of Resident #9's medical record was conducted and revealed a 10/10/22 nursing note that documented the resident was, alert and verbal but not at baseline and remained in bed this shift d/t 'feeling lousy.' The physician was notified and ordered for 911 to be called to send the resident to the hospital. There was no documentation in Resident #9's…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2023-03-30 · tag F0641 — pattern
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and medical record review, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#3, #6, #9, #2) of 14 records reviewed during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 3/22/23 at 1:21 PM an interview was conducted with Resident #3 who stated h/she had a fall in the bathroom. On 3/30/23 at 9:19 AM a review of Resident #3's medical record revealed the resident had a history of falls. Continued review of Resident #3's medical record revealed a nursing note dated 3/16/22 that stated the resident had an assisted fall/lowered to the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-30 · tag F0656 — failed to write and follow a full care plan — pattern
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review, and staff interview it was determined that facility staff failed to develop and initiate comprehensive, resident centered care plans for residents residing in the facility. This was evident for 6 (Resident #3, #4, #5, #6, #9, #10) of 14 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 3/22/23 at 1:18 PM the surveyor entered Resident #3's room and attempted to interview Resident #3. Resident #3 sat in the chair and stared at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-30 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and medical record review, it was determined the facility staff failed to evaluate and revise resident care plans to reflect accurate and current interventions. This was evident for 5 (Resident #3, #5, #1, #2, #12) of 14 residents reviewed during the annual survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On [DATE] at 1:18 PM an interview was conducted with Resident #3. Resident #3 was asked if h/she had any recent…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-30 · tag F0678 — failed to provide CPR when needed — pattern
    Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of resident medical records and interview with facility staff, it was determined that the facility failed to ensure that residents had only one Maryland Order for Life-Sustaining Treatment (MOLST) form in their paper medical record. This was evident for 4 (Residents #14, #1, #16, and #4) of all 17 residents present in the facility at the time of the survey. The findings include: The Maryland Orders for Life-Sustaining Treatment (MOLST) form is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. It was designed to ensure that healthcare providers throughout Maryland have a uniform system of communicating a resident's end-of-life wishes in the event of cardiac or respiratory arrest. Cardiopulmonary Resuscitation (CPR) is the act of attempting to revive someone one their heart or breathing have stopped. On [DATE] at 9:24 AM, a review was done of the paper medical records for all 17 residents in the facility. The review…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-30 · tag F0756 — failed to review each resident's drug regimen — pattern
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview it was determined the facility failed to 1) keep the pharmacy reviews with recommendations that identified irregularities in the resident's medical record and 2) report that a physician ordered parameter was not being monitored. This was evident for 4 (#4, #5, #10, #9) of 6 residents reviewed for unnecessary medications. The findings include: 1) On 3/23/23 at 1:40 PM a medical record review was conducted for Resident #4 and revealed progress notes that documented monthly pharmacy reviews were done on 1/18/23 with no recommendations and on 2/16/23 with no recommendations. The 3/9/23 pharmacy review documented, see report. There was no report found in the medical record for the 3/9/23 pharmacy review, therefore there was no documentation if the physician agreed or disagreed with the recommendation. 2) On 3/23/23 at 3:07 PM a medical record review was conducted for Resident #5 and revealed progress notes that documented pharmacy reviews were done on 1/18/23, 9/19/22, 6/7/22, and 5/10/22 that noted, see report. Further review of the…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-03-30 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, it was determined that the facility staff failed to: 1) discard expired food items, 2) label food items when opened, and 3) discard damaged food items. This was evident during an inspection of the kitchen, dry storage room, and kitchenette on the unit during the annual survey. The findings include: On 3/22/23 at 9:03 AM a tour of the kitchen was conducted with the Director of Food Service, Staff #20. Observation was made in the refrigerator of the following items: (1) opened gallon of Classic Gourmet tarter sauce with a best by date of 1/31/23 (1) opened gallon of [NAME] Brand Buttermilk Ranch dressing with a best by day of 1/18/23 (2) opened 32 oz. Tulkoff Brand horseradish with best by date of 5/18/22 and 5/15/22 respectively (1) opened gallon of Kens [NAME] Slaw Dressing with no date opened (1) opened gallon of Kens Thousand island dressing with a manufactured date of 3/8/22, with no date opened. Staff #20 stated those items should have been discarded. Observation was…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
Show the remaining 15 citations
  • Potential for harm · E2023-03-30 · tag F0842 — failed to keep accurate, complete medical records — pattern
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 6 (#4, #5, #10, #13, #2, #12) of 14 residents reviewed during the annual survey. The findings include. A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 3/23/23 at 1:40 PM a medical record review was conducted for Resident #4 and revealed the 3/9/23 pharmacy review documented, see report. There was no report found in the medical record for the 3/9/23 pharmacy review. 2) On 3/23/23 at 3:07 PM a medical record review was conducted for Resident #5 and revealed progress notes that documented pharmacy reviews were done on 1/18/23, 9/19/22, 6/7/22, and 5/10/22 that noted, see report. Further review of the medical record failed to produce…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of medical records and staff interview, it was determined that facility staff failed to notify a resident's physician when a resident displayed changes in their baseline condition. This was evident for 1 (Resident #4) of 4 residents reviewed for accidents during the annual survey. The findings include: On 3/29/23 at 9:32 AM a medical record review was conducted for Resident #4. A 3/13/23 at 1:12 AM nursing note documented, Resident has been showing some confusion on whether [h/she] went to restroom or not. Resident was noted leaning forward while on toilet and leaning towards the right while in the wheelchair. A 3/13/23 at 4:18 AM nursing note documented, Resident was sitting on side of bed attempting to go to restroom. Staff assisted with transfer to wheelchair. Resident began leaning to right side and unable to get up to get on commode. Writer noticed confusion again and resident was noncompliant with answers. DON (Director of Nursing) updated at 4:18 AM and stated resident has a history of being weak and then stronger and may need to rest in bed. A 3/13/23 at…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident and staff interview and policy review, it was determined that facility staff failed to report missing jewelry to the Administrator when first notified by the resident. This was evident for 1 (Residents #9) of 6 residents reviewed for missing personal items during the annual survey. The findings include: On 3/23/23 at 9:04 AM an interview was conducted with Resident #9. Resident #9 was asked if h/she had any missing personal property. Resident #9 stated that about 2 months ago, he/she was missing an 18-carat gold chain and a gold bracelet. Resident #9 stated it was reported to Staff #18 and Staff #18 stated she would look into it. On 3/28/23 at 9:31 AM the Nursing Home Administrator (NHA) was asked what the process was for missing resident items. The NHA stated, we go to see the resident and we interview and ask how, when, why and basic questions and anything they can tell us. We want to see them sooner than later. After we interview the person, we will talk to staff that might have worked that particular day in the unit or the staff that would have an impact on…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was identified for 1 (Resident #16) of 3 residents reviewed for hospitalization during the annual survey. The findings include: On 3/23/23 at 10:52 AM a review of Resident #16's medical record was conducted. A 10/29/22 nursing note documented, called to room @ 0945 with report of resident on floor in bathroom. Unable to move RLE (right lower extremity), c/o (complained of) severe pain. [name] and [name] notified, 911 called to transport to ED (emergency department). There was no documentation in Resident #16's medical record as to what was done for the resident prior to transfer and if the resident understood where h/she was being transported to and why h/she was being transported. On 3/28/23 at 11:33 AM Staff #3 was interviewed and stated, the nurses usually document in a progress note. Staff #3 was shown that there was no…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0710 — isolated
    Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of resident medical records and interview with facility staff, it was determined that a resident's attending physician failed to supervise and respond to abnormal laboratory test results. This was evident for 1 (Resident #2) of 6 residents reviewed for unnecessary medication. The findings include: Potassium is an electrolyte that is essential in maintaining fluid balance and in the proper functioning of muscle contractures and nerve impulses. Having too much potassium is dangerous and can lead to life-threatening heart problems, muscle weakness, and paralysis. Normal potassium levels are 3.5 to 5.2 miliequivalents per liter (mEq/L). Potassium is measured by taking a blood sample. Resident #2's medical record was reviewed on 3/24/23 at 2:02 PM. The review revealed that Resident #2 had multiple abnormal potassium levels in February and March 2023. Lab results revealed that the resident had a potassium level of 5.5 mEq/L on 2/7, 5.3 on 2/9, and 5.4 on 3/7. Lab results for potassium were not available in the medical record for any other day in February and March 2023.…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to monitor the heart rate prior to administering a blood pressure medication per physician's orders. This was evident for 1 (Resident #9) of 6 residents reviewed for unnecessary drugs during the annual survey. The findings include: On 3/30/23 at 12:34 PM a review of Resident #9's medical record was conducted and revealed a physician's order for Metoprolol Succinate ER Tablet, Extended Release 50 mg. to be given every day. The order stated to hold the medication for a SBP (systolic blood pressure) less than 100 or HR (heart rate) below 60. The top number of the blood pressure refers to the amount of pressure in the arteries during the contraction of the heart muscle. This is called systolic pressure. Review of Resident #9's March 2023 Medication Administration Record (MAR) documented that the SBP was being monitored but not the heart rate. Further review of the December 2022, January 2023, and February 2023 MARS also failed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, it was determined that facility staff failed to ensure residents were free from significant medication errors as evidenced by failing to follow a physician's order related to holding blood pressure medications and administering insulin if outside of physician ordered parameters. This was evident for 3 (Resident #4, #10, #2) of 6 residents reviewed for unnecessary medications during the annual survey. The findings include: Blood pressure is a measurement of the pressure that the blood places on the arteries as it is moving through the arteries. The top number is the systolic pressure, which is a measurement of the pressure when the heart pumps the blood out into the arteries. The bottom number is the diastolic pressure which is a measurement of the pressure when the heart is between beats (resting). A fingerstick (FS) is when the fingertip is pricked with a small needle called a lancet to produce a blood drop. The blood drop is then placed against the test strip in the glucose meter, and the meter shows the blood sugar level within…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and medical record review, it was determined that the facility failed to ensure that humidified bottles for oxygen delivery were discarded in a timeframe for good infection control practice. This was evident for 1 (Resident #14) of 1 resident reviewed for respiratory care. The findings include: Oxygen therapy is a medical treatment in which oxygen is added to the air that a resident breathes. The simplest and most common form of oxygen delivery is through a nasal cannula which delivers oxygen directly into a resident's nostrils through a flexible tube. Medical oxygen lacks water content and is often humidified to increase comfort and decrease the drying effect of the oxygen. Nasal cannula systems are often humidified by attaching a sterile humidifier bottle to the delivery system. The oxygen bubbles through the sterile water prior to reaching the resident. If the water is not sterile, the oxygen could deliver pathogens directly to the resident's airway, increasing the risk of infection. Resident #14's room was observed on 03/27/23 at 02:12 PM. During…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-03-30 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interview with facility staff, it was determined that the facility failed to ensure that resident's mattresses were sized to securely fit the bed frames. This was evident for 1 (Resident #5) of 17 resident beds observed during the survey. The findings include: Resident #5's room was observed on 3/22/23 at 10:20 AM. During the observation, a gap of approximately 6 inches was seen between the mattress and the end of the bed. The Maintenance Director was interviewed on 3/28/23 at 10:19 AM in Resident #5's room. During the interview, the Maintenance Director inspected Resident #5's bed and confirmed that the mattress was not the standard size and did not fit the bed correctly. The Maintenance Director stated that he would find a more appropriate mattress and switch it out. On 3/28/23 at 10:56 AM, the Maintenance Director stated to the surveyor that a larger mattress had been located and placed on the bed. Resident #5's bed was observed on 3/28/23 at 2:56 PM. The mattress fit much better between the head and the foot of the bed.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-01-04 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview it was determined the facility staff failed to ensure that the information used to complete the Minimum Data Set (MDS) comprehensive assessments was accurate for: 1) the use of restraints for Resident #7; and 2) skin conditions for Resident #27. This was evident for 2 of 3 residents reviewed for MDS accuracy during this complaint revisit survey. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment is part of a broader RAI (Resident Assessment Instrument) process. The RAI process ties the assessment and care plan to the delivery of care to meet the needs of the resident. MDS or Minimum Data Set coordinators are nurses that are tasked to ensure that patient servicing is well documented especially during the assessment phase in facilities…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-01-04 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview it was determined the facility staff failed to provide evidence of ongoing monitoring and documentation of target symptoms for the administration of psychotropic medications to determine the efficacy and necessity of these medications for Residents #7 and #5. This was evident for 2 of 3 residents reviewed for unnecessary medications during this survey. MDS or Minimum Data Set Coordinators are nurses that are tasked to ensure that patient servicing is well documented especially during the assessment phase in facilities that are accredited or offer Medicaid or Medicare services. The findings include: 1)The facility failed to demonstrate consistent monitoring and documentation of target symptoms for Celexa and Trazadone, the use of non-pharmacological interventions, and provide a rationale for the simultaneous use of two antidepressants to determine the necessity and efficacy of the medications for Resident #7. Medical record review revealed that Resident #7 was a long-term care resident with diagnoses that included but were not…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-03-30 · tag F0582 — widespread
    Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of resident records and interview with facility staff, it was determined that the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to residents who were discharged from medicare with days remaining and intended to remain at the facility receiving non-skilled care. This was evident for all medicare discharges that occurred in the past six months in which residents remained in the facility. The findings include: Nursing facilities are required to issue certain notices to residents who are being discharged from Medicare services and have benefit days remaining. These notices include the Notice of Medicare Non-Coverage (NOMNC) at least 48 hours prior to Medicare services ending and the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) if the resident indicates intent to remain in the facility. The purpose of the forms are to inform the beneficiary of financial liability for ongoing care and to inform them of their right to appeal. On 3/23/23 at 11:16 AM, the facility provided the survey team with NOMNC forms for all…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-03-30 · tag F0623 — widespread
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, medical record review, and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 3 (Resident #9, #16, #4) of 3 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 3/23/23 at 9:17 AM an interview was conducted with Resident #9. Resident #9 was asked if h/she had been sent to the hospital recently. Resident #9 stated, yes, to rule out a vein blockage. Resident #9 was asked if h/she received anything in writing stating that h/she was being transferred to the hospital. Resident #9 stated that h/she did not receive written notification of transfer. On 3/24/23 at 8:27 AM a review of Resident #9's medical record was conducted and revealed a 10/10/22 nursing note that documented the resident was, alert and verbal but not at baseline and remained in bed this shift d/t 'feeling lousy.' The physician was notified and ordered for 911 to be called to send the resident to…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-03-30 · tag F0625 — widespread
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy upon transfer of a resident to an acute care facility. This was evident for 3 (#9, #16, #4) of 3 residents reviewed for hospitalization during the annual survey. The findings include: 1) On 3/23/23 at 9:17 AM an interview was conducted with Resident #9. Resident #9 was asked if h/she had been sent to the hospital recently. Resident #9 stated, yes, to rule out a vein blockage. Resident #9 was asked if h/she received a copy of the bed hold policy when h/she was transferred to the hospital. Resident #9 stated, no. On 3/24/23 at 8:27 AM a review of Resident #9's medical record was conducted and revealed a 10/10/22 nursing note that documented the resident was, alert and verbal but not at baseline and remained in bed this shift d/t 'feeling lousy.' The physician was notified and ordered for 911 to be called to send the resident to the hospital. There was no evidence in Resident #9's medical record that a copy of the bed…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2023-03-30 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, review of posted staffing sheets, and staff interview it was determined that the facility failed to post, the total number and actual hours worked by categories of Registered nurses, Licensed practical nurses, and Certified nursing assistants. This was evident for 7 of 7 days of the annual survey. The findings include: On 3/22/23 at 8:00 AM, upon entry to the facility's lobby, the daily nursing staffing form was posted on the receptionist counter in an acrylic frame. The nursing staff form documented licensed nursing staff and unlicensed staff. The form documented the number of day shift, evening shift, and night shift licensed nursing staff in the first column and the same for unlicensed staff in the second column. At the top of the form it stated, FTE (full time employee) = 8 hours. The form failed to separate the staff out to identify how many were registered nurses, licensed practical nurses, certified medicine aides, and geriatric nursing assistants. The form also failed to have the total number of hours worked. One would have to add up the number of staff…

    This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
BRUSCHE, DEBORAHIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2021
KLEIBUSCH, LOISIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2024
PICHE, MARIEIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2021
POCOCK, BARBARAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 07/01/2021

CMS files one row per role, so the 8 rows in the source record cover these 4 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$3.4M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$86K
Related-party expense1% of expenses

This home reported $86K paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$714per resident / day
operating cost
$21,699per month
≈ monthly operating cost
$274per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MD

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Maryland Medicaid page.

Typical monthly cost in Maryland
$12,927/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$7,173/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215354. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-25, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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