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Lochearn Nursing Home, LLC

4800 Seton Drive, Baltimore, MD 21215 · For profit - Corporation · 200 certified beds · (410) 358-3410 Medicare & Medicaid certified

Call the home — (410) 358-3410 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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
Worth asking about
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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.

5/5
CMS overall
5 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 4 of 5
StaffingFrom payroll records (PBJ) 3 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Urgent care / clinic
4701 Mount Hope Dr Ste C · (410) 585-0467 · Call to confirm hours
Pharmacy
Rite Aid0.5 mi
4600 W Northern Pkwy · (410) 358-9777 · Call to confirm hours
Grocery
5708 Wabash Ave · (410) 764-2414 · Call to confirm hours
Park
Typically dawn to dusk
Place of worship

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 5 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 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 5 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 rating5★
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 increased14.2%20.4%15.4%typical
Long-stay residents who lose too much weight8.4%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.5%0.5%0.9%better
Long-stay residents with a urinary tract infection3.6%1.5%2.0%worse
Long-stay residents with depressive symptoms9.3%22.8%6.5%better than state — see note marked double-dagger 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 injury3.0%2.4%3.3%better
Long-stay residents whose ability to walk worsened27.6%22.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication9.4%16.7%18.9%better
Long-stay residents given the seasonal flu vaccine97.7%96.6%95.3%typical
Long-stay residents with pressure ulcers6.9%5.9%4.7%worse
Long-stay residents with worsening bladder/bowel control26.5%25.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table9.2%13.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.2%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine73.9%80.6%79.4%typical
Short-stay residents rehospitalized after admission13.1%21.0%22.6%better
Short-stay residents with an outpatient ER visit5.8%9.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.251.331.67better
Long-stay outpatient ER visits per 1,000 resident days0.591.201.80better

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.

55.5% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 313 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

55.5%U.S. median 51.5%
Got home and stayed home
10.5%U.S. median 10.7%
Went back to hospital
58.1%U.S. median 56.6%
Met the expected recovery
0.29U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.09hours / resident / day
Occupational therapy
0.08hours / resident / day
Speech therapy

Met the expected recovery: 58.1% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 136 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. 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 SNF55.5%CMS range 48.7–62.051.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.5%CMS range 7.9–13.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge58.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge60.3%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.2%100.0%Oct 2024–Sep 2025CMS makes no comparison for this 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.5%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.2%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization8.1%CMS range 5.6–11.27.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.121.02Oct 2022–Sep 2024CMS makes no comparison for this 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

0.44
RN hours/ resident / day
1.23
LPN hours/ resident / day
2.24
Aide hours/ resident / day
3.91
Total nurse hours/ resident / day
0.27
RN hoursweekends
38.1%
Total nursing turnover
34.8%
RN turnover

How full it usually is: this home is certified for 200 beds and averages 191.7 residents a day — about 96% occupied, or roughly 8 beds typically open. It runs essentially full — expect a waiting list. 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 3.91 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.44 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.24 is below 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 3.43 hrs/resident/day on weekends vs 4.11 on weekdays — 17% thinner on weekends. RN hours go from 0.51 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 38% is about the same as 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

7
deficiencies at the latest standard inspection (2026-01-08)
2
at the previous standard inspection (2024-07-19)

Deficiencies are more than at the previous inspection — worsening. 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.

30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · Dcited before2026-01-08 · 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 observations and interviews, it was determined that the facility failed to treat residents with dignity and respect as evidenced by staff standing over residents while assisting them to eat. This was evident for 1 (resident #52) out of 1 resident observed for dignity during the annual survey.Findings include:On 01/05/2026 at 9:29 AM Resident #52 was observed sitting in a wheelchair in the Activities room at the table with their breakfast tray in front of them. Geriatric Nursing Assistant (GNA) #16 was standing to the left of the resident with a fork in hand and feeding the resident. Additionally, observed seated at the table were 3 other residents in their wheelchairs, Activities Assistant Staff #25, and a vacant chair at the opposite end of the table. This Surveyor asked GNA #16 if the facility has a Feeder program and training; GNA staff #16 stated No. Then asked, was this resident designated to be assisted or fed; GNA staff #16 stated we encourage him/her to eat and we help sometimes. When asked if a chair is available to use while feeding the resident when needed, GNA…

    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 · D2026-01-08 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    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 resident record reviews and staff interviews, it was determined that the facility failed to ensure the accuracy of the resident's Minimum Data Set (MDS). This was evident for 1 resident (Resident #3) out of 10 residents reviewed during the recertification survey.On 01/06/2026 at 1:06 PM, the surveyor reviewed Resident # 3's medical records. The resident record review revealed that, according to Resident # 3's January 2026 Medication Administration Record and current medication orders, Resident #3 did not receive insulin. It was documented in Resident #3's January 2026 Medication Administration Record and current medication orders that Resident #3 received a 50 mg tablet of Januvia, an oral anti-diabetic medication, each morning for type 2 diabetes.On 01/06/2026 at 1:32 PM, the surveyor asked the Assistant Director of Nursing staff #18 if Resident #3 received insulin. During the interview, staff #18 stated that Resident #3 did not receive insulin, and that Resident #3 received Januvia.On 01/06/2026 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 · Dcited before2026-01-08 · tag F0657 — failed to keep the care plan current — isolated
    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

    Based on review of resident medical records, observation and interviews, it was determined that the facility failed to perform appropriate revisions to resident care plan. This was evident for 1 resident (Resident #5) out of 10 residents reviewed during the survey. The findings include: Review of Resident #5's medical record on 01/08/2026 at 8:30 AM revealed a care plan with a problem area created on 08/04/2022, revised on 11/14/2025 stating that Resident #5 was an Elopement Risk with an approach to apply wanderguard: check placement Q shift and function Q Day. Further review of Resident #5's medical record revealed a Wandering Risk Scale - V3 assessment performed on 11/17/2025 with a score of 3 indicating that Resident #5 was a low risk of wandering. During observation rounds on 01/08/2026 at 9:15 AM Resident #5 was observed not wearing a wanderguard. During an interview on 01/08/2026 at approximately 10:10 AM the Director of Nursing confirmed and stated, [Resident #5's] current care plan was incorrect and needs to be updated, [Resident #5] is not a wander risk and should not be…

    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 · Dcited before2026-01-08 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and review of facility documentation, the facility failed to properly store medications, biologicals and resident food items under proper temperature controls. This was evident for 2 out of the 4 medication, biologicals and resident food refrigerators observed during the annual survey. The findings include the following: During observation rounds, interview and review of facility documentation of the 3rd floor medication and resident food storage rooms on 01/07/2026 at 10:26 AM with staff # 4, refrigerator #1 was found to have several resident's food items. On the outside of this refrigerator was a Refrigerator Temperature Form for the month of January 2026 stating that temperatures must be between 38 and 42 degrees. On 01/07/2026 at 05:00 AM staff recorded that the refrigerator was 45 degrees Celsius. At the time of the observation the refrigerator reading was 45 Fahrenheit. A second refrigerator #2 was found to have several medications and biologicals for facility residents. On the outside of this refrigerator was a Refrigerator Temperature Form…

    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 · D2026-01-08 · 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, record reviews and interviews, it was determined that the facility failed to implement infection control practices to ensure oxygen equipment was dated when put into use. This deficient practice was evident for 2 (resident #37 and #135) of 3 residents reviewed for oxygen equipment during the annual survey.The findings include: 1. On 1/5/25 at 8:05 AM, Resident #37 was observed with an oxygen setup. The humidifier bottle and oxygen tubing attached to the resident's oxygen concentrator were noted to be in use but were not dated. At that time, the surveyor located Staff #4, who was identified as responsible for the care of Resident #37. Staff #4 confirmed the humidifier bottle and tubing were in use and acknowledged that they were not dated as required. Staff #4 then obtained a new humidifier bottle and oxygen tubing, placed them on the resident's concentrator, and marked both with the date. At 10:52 AM, the Nursing Home Administrator and Director of Nursing were informed of the surveyor's findings. 2. 01/05/2026 at 9:23 AM during initial observation, resident…

    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 · D2026-01-08 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on administrative records reviews and interviews it was determined that the facility failed to document and ensure that geriatric nursing assistants' (GNAs) human resources and clinical education records reflected the required 12 hours of annual clinical training/in-services as required. This was evident to be true for 5 out of 5 (GNA # 15, #16, #17, #21, #22 ) geriatric nursing aide clinical education and human resources records reviewed during the survey.The findings include: On 01/08/2026 at approximately 09:36 AM the surveyor requested the human resources records of six employees from the DON that held the job descriptions of geriatric nursing assistants. On 01/08/2026 the following GNA human resources and clinical education records were reviewed by the surveyor at 11:00 AM on : GNA # 15, #16, #17, 321, and #22. On 01/08/2026 12:34 PM The surveyor interviewed the ADON regarding the evidence/documentation/compliance requirements related to the annual clinical education and training for geriatric nursing assistant staff. The ADON stated that the annual hands on clinical…

    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 · D2025-10-08 · 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 complaint, record review, and interview, it was determined that the facility staff failed to inform a resident's representative of a fall with injury and subsequent transfer to the hospital. This was evident for 1 (#7) of 12 residents reviewed for complaints during a complaint survey.The findings include: On 10/2/25 at 9:16 AM a review of complaints 326854 and 2561080 alleged that Resident #7 was transferred and sustained a fall with injury and that family were not notified On 10/2/25 at 9:16 AM Resident #7's medical record was reviewed and revealed a 6/6/25 at 13:01 (1:01 PM) nurse's note that documented, during care while attempting to place Hoyer pad under pt., pt. turned too far over rolling out of bed. The note continued, MD made aware of pt. fall. Review of a 6/6/25 at 13:09 (1:09 PM) change in condition note documented that the physician was aware of the fall and ordered an x-ray to the knee and pain medication. Review of a 6/6/25 at 22:05 (10:09 PM) change in condition note documented that the results of the x-ray were received and Resident #7 had a right knee…

    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 · D2025-10-08 · tag F0627 — isolated
    Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
    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 a complaint, medical record review and interviews, it was determined the facility staff failed to ensure home health services were set up for a resident at discharge (Resident #19). This was evident for 1 of 3 residents reviewed for discharge during a complaint survey. The findings include:Review of Complaint 326835 was conducted on 10/2/25 for a concern Resident #19 was discharged without home health services.Review of Resident #19's medical record on 10/2/25 revealed the Resident was admitted to the facility in April 2024 following a hospitalization with a diagnosis to include POTS (Postural Orthostatic Tachycardia Syndrome). Review of the hospital Discharge summary dated [DATE] revealed the Resident received daily IV fluid bolus at home prior to admission.Further review of Resident #19's medical record revealed the Resident was receiving IV fluid daily in the facility.On 7/26/24 at 12:08 PM Staff #23, former Social Services, documented progress meeting held. Staff #23 also documented…

    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 · Dcited before2025-10-08 · tag F0657 — failed to keep the care plan current — isolated
    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

    Based on observation, medical record review, and interviews, it was determined that facility staff failed to thoroughly evaluate and revise a resident's plan of care after each MDS (Minimum Data Set) assessment to reflect accurate and current interventions (Resident #17). This was evident for 1 of 19 residents reviewed during a complaint survey. The findings include: Minimum Data Set- The MDS is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions A care plan is a guide that addresses each resident's unique needs. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Review of Resident #17's medical record on 10/2/25 revealed the Resident was admitted to the facility in August 2024 with diagnosis to include spinal cord injury and quadriplegia. Further review of Resident #17's medical record revealed the staff conducted an MDS Quarterly Assessment on 9/18/25 and coded the Resident with a BIMS (Brief Interview of Mental…

    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 · Dcited before2025-10-08 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on complaint, medical record review, and interviews, it was determined the facility staff failed to thoroughly assess a resident for pain after a fall with fracture. This was evident for 1 (#7) of 12 residents reviewed for complaints during a complaint survey.The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. On 10/2/25 at 9:16 AM a review of complaints 326854 and 2561080 alleged that Resident #7 was rolled out of bed during care and sustained a fall with injury. The complaint alleged that during a phone call Resident #7 was screaming in pain periodically during the call. The complaint alleged that Resident #7, laid with a broken leg for more than 6 hours before being transferred to the hospital. On 10/2/25 at 9:16 AM…

    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
Show the remaining 20 citations
  • Potential for harm · Dcited before2025-10-08 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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 (Resident #16). This was evident for 1 of 19 residents reviewed during a complaint 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. Review of Resident #16's medical record was conducted on 10/2/25 for Complaint 326847 in December 2024 related to the facility managing the Resident's diabetes. Review of the Resident's medical record revealed the Resident was admitted to the facility in January 2024 with a diagnosis to include Diabetes. Review of Resident #16's December 2024 Medication Administration Record revealed on 12/2/24 the facility staff documented the Resident's 12:00 PM blood sugar (BS) was 401 but failed to document 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 · E2024-07-19 · tag F0883 — failed to offer flu and pneumonia vaccines — pattern
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    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, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to ensure five of five residents (Resident (R) 40, R158, R73, R7, and R96) reviewed for influenza vaccines had consents signed, including the risks and benefits explained to the resident and/or representative prior to the administration of the vaccine. The facility further failed to offer an additional pneumococcal vaccine to two of five residents (R73 and R96) reviewed for pneumococcal vaccines out of a total sample of 39 residents. The failure of not offering/providing the additional pneumococcal vaccine increased the risk for residents to contract pneumonia. The failure for not obtaining consents and providing education to the resident and/or representative prior to administering the influenza vaccine did not give the resident and/or representative the ability to make an informed decision prior to the vaccine being administered. Findings include: 1.…

    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 · D2024-07-19 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined that the facility failed to place a discharge summary on resident's medical record after discharge. This was evident for 2 (#919 and #923) of 89 residents reviewed during the survey. The findings include: 1) Review of resident #919's medical record on 7/19/24 at 9:30 AM revealed no evidence of a discharge summary after the resident discharged from the facility on 2/4/24. In an interview with the Director of Nursing (DON) on 7/19/24 at 10:42 AM, the surveyor told the DON that he/she was unable to locate the provider discharge summary after reviewing the resident's medical record. The DON reviewed the progress notes and agreed that the facility failed to place a discharge summary on the resident's medical record. 2) Review of resident #923's medical record on 7/19/24 at 7:51 AM revealed no evidence of a discharge summary after the resident from the facility on 4/29/22. In an interview with the DON on 7/19/24 at 10:42 AM, the surveyor told the DON that he/she was unable to locate the provider discharge summary after reviewing 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 · Dcited before2024-07-19 · tag F0842 — failed to keep accurate, complete medical records — isolated
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the medical record and interview with staff it was determined the facility staff failed to maintain complete and accurately documented medical records. This was evident for 2 (#924 and #914) of 89 residents reviewed during the survey. The findings include: 1) A Facility Reported Incident regarding an allegation of abuse on 2/9/22 involving Resident #924 was reviewed on 7/15/24 at 11:52 AM. The facility investigated the allegation and was unable to conclude that abuse occurred. The facility's final report indicated a nursing assessment was done and the resident had no injuries. The report also identified a plan which included but was not limited to a psychiatry consult for Resident #924. Resident #924's medical record was reviewed on 7/15/24 at 1:00 PM. The surveyor was unable to find documentation that a psychiatry consult was obtained in response to the incident. The surveyor was also unable to find a documented nursing assessment for injury of Resident #924 after the allegation of abuse 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 Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-06-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    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.
    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 1.) Facility staff failed to maintain a safe environment. This was observed during the initial tour of the fifth floor during an annual recertification survey; and 2.) Facility staff failed to put a system in place to provide housekeeping and maintenance services necessary to maintain a sanitary, order and comfortable interior and wheelchairs for residents. This was found to be true for 3 of 6 resident floors during the environmental observations of the facility. The findings include: 1.) Facility staff failed to maintain a safe environment. During an observation of the fifth-floor west unit activity area on 05/30/2019 at 9:42 AM, the surveyor observed exposed wires coming from an electric wall fixture leading to the solarium air conditioner unit. The nursing unit manager was made aware of the observation and called the maintenance department manager. 2.) Facility staff failed to put a system in place to provide housekeeping and maintenance services…

    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 before2019-06-04 · 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 staff failed to maintain the medical record in the most complete and accurate form for a resident. This was evident for 1 of 57 residents )Resident #69) selected for medical record review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. Medical record review revealed that on 11/15/2018 the physician ordered: audiology consultation as needed, and eye consultation as needed. Further record review revealed the physician ordered: dental consultation. Throughout the survey process, it was determined the facility staff failed to obtain the dental consultation. Interview with Resident #69 on 5/29/2019 at 12:30 PM revealed no concerns related to teeth. The resident denied any chewing difficulties. Interview with the Director of Nursing on 6/3/2019 at 10:00 AM revealed the facility staff entered the order…

    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 · Dcited before2019-06-04 · 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 — the official record, unedited, may be distressing

    Based on interview and observation, it was determined the nursing staff failed to provide a resident with the most dignified existence. This was evident for 1 of 1 resident (Resident #86) reviewed during the annual survey for dignity. The findings include: On 5/29/2019 at 10:34 AM Resident #86 who is dependent on facility staff for all care, including dressing, was observed sitting in his/her wheelchair wearing black sneakers with white soles. The sneakers had Resident #86's last name written in black marker on the lateral side of the sneaker and on the bottom. The name was clearly visible by anyone. Resident #86 also had 9 pairs of shoes piled up under the head of his/her bed that were covered in dust. On 6/03/2019 at 12:30 PM during interview and tour with Unit Manager #17 the 9 pair of shoes were still piled up under the head of Resident #86's bed and covered in dust. The black sneakers observed on 5/29/19 were by the bed with Resident #86's last name visible from the doorway. The facility failed to honor Resident #86's dignity and the Unit Manager #17 was made aware on 06/03/19.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-04 · tag F0656 — failed to write and follow a full care plan — isolated
    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 medical record review and interview, it was determined the facility staff failed to: 1.) initiate a resident specific care plan with interventions for Resident #69 and 2.) failed to initiate a comprehensive care plan for Resident #174 to address dental needs. This was evident for 1 of 3 resident selected for review of hemodialysis and 1 of 4 residents selected for review of dental concerns during the survey process and 2 of 57 residents selected for review during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Care Area Assessments (CAAs) are part of this process and provide the foundation upon which a resident's individual care plan is formulated. MDS assessments are completed for all residents in certified nursing homes, regardless of source of payment for 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 · Dcited before2019-06-04 · tag F0657 — failed to keep the care plan current — isolated
    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

    Based on medical record review and interview it was determined the facility staff failed to review and revise the care plan for Resident #124 to reflect accurate and current interventions. This was evident for 1 of 57 residents reviewed for care plans during the survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions and assure the resident's needs are attended to. The care plan is to be reviewed and revised at each…

    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 · D2019-06-04 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review and interview, it was determined the facility staff failed to provide services that would allow residents the ability to achieve the greatest independence with performing Activities of Daily Living (ADL) to a resident. This was evident for 1 of 57 residents (Resident #90) selected for review during the survey process. The findings include: Activities of daily living are routine activities people do every day without assistance. There are six basic ADLs: eating, bathing, getting dressed, toileting, transferring and continence. Medical record review for Resident #90 revealed on 11/16/2018 the physician ordered: sling on the right arm for support old stroke when OOB (out of bed) in wheelchair. Many people who have a stroke are left with problems with one of their arms. Proper arm care after a stroke can help treat these problems. It can also help prevent new problems. Arm care after a stroke includes techniques such as proper positioning. The shoulder is a key problem area after a stroke. The shoulder blade and the upper arm bone come…

    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 · D2019-06-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation and interview, it was determined, the facility staff failed to promote an environment free from potential accidents for Resident #69. This was evident for 1 of 2 residents selected for review of accidents and 1 of 57 residents selected for review during the annual survey. The findings include: 1a.) The facility staff failed to maintain a bed in low position as ordered by the physician. Medical record review revealed on 8/16/2018 the physician ordered low bed when resident in bed and unattended. Surveyor observation of Resident #69 on 5/29/2019 at 11:00 AM, 5/29/2019 at 1:00 PM, 5/31/2019 at 9:00 AM and 6/1/2019 at 9:10 AM revealed the resident in bed, unattended; however, the facility staff failed to position the bed in a low position. Observation at the for different times revealed the bed to be approximately 3 feet from the floor. A low bed is approximately 6 inches off the floor. 1b.) The facility staff failed to apply fall mats to the bedside as ordered by the physician. Medical record review revealed on 2/17/2019 the physician ordered…

    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 · Dcited before2019-06-04 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview it was determined that 1.) Facility staff failed to thoroughly assess the need for pain medication for Resident (#33). This was evident for 1 of 4 resident selected for pain assessment and 1 of 57 residents selected for review during the annual survey; and 2.) Failed to document the administration of pain medicine and monitor its effectiveness. This was true for 1 out of the 57 residents (Resident #107) reviewed during the annual recertification survey. The findings include: 1.) Facility staff failed to thoroughly assess the need for pain medication Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain…

    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 · D2019-06-04 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, staff interviews and review of facility daily Controlled Drugs-Count per shift records, it was determined that the facility failed to accurately complete the record each shift. This was evident for 2 of 8 medication storage carts reviewed. The findings include: Observation on 5/29/2019 at 9:00 AM on the 3rd floor Team 1 medication cart the off going nurse failed to sign the Controlled Drugs-Count Record on 5-29-19 at 11:00 PM that the controlled drug count was accurate. Observation on 5/29/2019 at 9:20 AM on the 3rd floor Team 2 medication cart the on-coming nurse failed to sign the Controlled Drugs-Count Record on 5-29 at 3:00 PM that the controlled drug count was accurate. Also, on 05/30/2019 the on-coming nurse failed to sign the Controlled Drugs-Count Record at 7:00 AM that the controlled drug count was accurate. The above findings were confirmed with 3rd floor unit manager on 5/30/2019 at 9:45 AM and the Nurse Educator and the Corporate Nurse on 05/30/2019 at 9:50 AM.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-04 · 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 interview, it was determined the facility staff failed to document the heart rate and blood pressure for Resident #24 when the physician ordered parameters. This was evident for 1 of 6 residents selected for unnecessary medication review and 1 of 57 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #24 revealed that on 2/21/2019 the physician ordered: Coreg 6.25 milligrams (mgs) by mouth 2 times a day for heart failure, hold for systolic blood pressure (top number) less than 110 and heart rate less than 60. Coreg is used alone or in combination with other medications to treat high blood pressure. Coreg is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. On 2/22/2019 the physician ordered Lisinopril 10 mgs by mouth every day for blood pressure, hold for systolic blood pressure less than 100 or heart rate less than 60. Lisinopril is used to treat blood pressure. Review of…

    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 · D2019-06-04 · 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 — the official record, unedited, may be distressing

    Based on medical record review and interview, it was determined the facility staff failed to follow the physician order for the administration of as needed psychotropic medications for Resident #107. This was evident for 1 of 57 residents selected for review during the survey process. The findings include: Medical record reviewed for Resident #107 revealed that on 5/07/19 the physician ordered: Ativan 1.0 mg (milligrams), every 12 hours as needed for anxiety, times 14 days. Ativan among others, is a benzodiazepine medication. It is used for anxiety disorders. Anxiety is a nervous disorder characterized by a state of excessive uneasiness and apprehension, typically with compulsive behavior or panic attacks and can be displayed by various behaviors or verbalizations. A review of Resident #107's Medication Administration Record revealed that Resident #107 received 1 mg of Ativan on 5/22/19 and 5/23/19. Interview with the Director of Nursing on 5/31/19 at 8 AM confirmed that the physician order for as needed Ativan was not discontinued on 5/21/19 as ordered.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-06-04 · tag F0761 — failed to label and store drugs safely — isolated
    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.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, it was determined the facility staff failed to 1.) Properly store medications. This was observed once during an annual recertification survey; and 2.) Failed to ensure that medications were disposed of in a proper manner. This was evident for 1 of 3 facility staff observed during medication pass review. The findings include: 1.) Facility staff failed to properly store medications. An observation was made on 05/30/19 at 12:30 PM on the fifth floor at the nursing station. The surveyor observed an unattended and unlocked medication cart. The medication cart held medications for the resident's residing on the fifth floor. No nursing staff members were attending the medication cart at the time of the observation. 2.) Facilty staff failed to ensure that medications were disposed of in a proper manner. On 5/30/2019 at 9:30 AM Staff #3 was observed administering medications to Resident #57 and the resident refused 2 Senexon tablets (laxative). After completing the medication pass Staff #3 disposed of the two Senexon tablets in Resident #57's trash can and not in a…

    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 · D2019-06-04 · tag F0924 — isolated
    Put firmly secured handrails on each side of hallways.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview it was determined that the facility staff failed to ensure hand rails were secured firmly to the wall. This was found to be true on 1 of 6 floors (6th floor) observed during the survey. This deficient practice has the potential to affect all residents, staff, and visitors on the unit. The findings include: On 5/29/2019 at 08:56 AM a tour of the facility's 6th floor was conducted. During this tour the handrail between the two elevator doors was observed to be loose and not securely affixed to the wall. The Administrator and the Director on Maintenance Staff #12 was made aware of surveyor's findings during an interview on 6/4/2019 at 1:00 PM.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2026-01-08 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    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, interview and document review, the facility failed to provide resident's rooms that measured at least 80 square feet per resident in 77 of 77 multi-resident rooms. Rooms 100, 102, 103, 104, 105, 107, 108, 109, and 110, measured 150 square feet. Rooms 300, 325, 326, 327, 331, 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446, 447, 500, 511, 512, 523, 524, 525, 527, 531, 532, 535, 536, 544, 545, 547, 600, 611, 612, 621, 622, 623, 624, 625, 626, 627, 631, 632, 633, 634, 635, 636, 637, 641 and 642 measured 155 square feet. This failure had the potential for residents not to have reasonable privacy or adequate space.The findings include:On 1/5/2026 at 10:51, the NHA staff #1 provided an untitled document letter from the Centers for Medicare & Medicaid Services (CMS) dated 10/11/2024 which indicated the facility requested a waiver for the residents' room that did not measure 80 Square feet per resident…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2024-07-19 · tag F0912 — pattern
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and document review, the facility failed to provide resident's rooms that measured at least 80 square feet per resident in 77 of 77 multi-resident rooms. Rooms 100, 102, 104, 105, 107, 108, 109, and 110, measured 150 square feet. Rooms 300, 325, 326, 327, 331, 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 427, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446, 447, 500, 511, 512, 523, 524, 525, 527, 531, 532, 535, 536, 544, 545, 547, 600, 611, 612, 621, 622, 623, 624, 625, 626, 627, 631, 632, 633, 634, 635, 636, 637, 641 and 642 measured 155 square feet. This failure had the potential for residents to not have reasonable privacy or adequate space. Findings include: On 07/17/24 at 5:17PM, the Regional Director of Operations provided an untitled document from the Centers for Medicare & Medicaid Services (CMS) dated 07/16/19 which indicated the facility requested a waiver for the residents' room that did not measure 80 Square feet per resident in multi resident bedrooms. The document indicated the following…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · Ccited before2019-06-04 · tag F0912 — widespread
    Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
    What the surveyor found here — the official record, unedited, may be distressing

    Based upon surveyor observation it was determined that resident rooms did not measure at least 80 square feet per resident in multi-resident bedrooms. The findings include: On 5/29/2019 at 8:00 AM a tour of the facility was conducted. Tour of the facility revealed the following multi-resident rooms measured 150 square feet: Rooms 100, 102, 103, 104, 105, 107, 108, 109, 110 The following multi-resident rooms were revealed to measure 155 square feet: Rooms 300, 325, 326, 327, 331. 332, 333, 334, 335, 336, 337, 338, 341, 342, 346, 400, 411, 412, 421, 423, 424, 425, 426, 427, 431, 432, 433, 435, 436, 437, 438, 441, 442, 444, 446,447,501,511,512,523,524, 525,527,531,532,535,536,544, 545,547,600,611,612,621, 622,623,624,625, 626,627, 631,633,634,635,636,637,641 and 642. The findings were confirmed with the Administrator on 5/30/2019 at 3:00 PM.

    Environmental 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.

Part of a chain

This home belongs to FUTURE CARE/LIFEBRIDGE HEALTH — 18 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.8+1.2 vs chain
Health inspection 4 of 53.4+0.6 vs chain
Staffing 3 of 53.5-0.5 vs chain
Quality measures 5 of 54.3+0.7 vs chain
The other 17 homes this chain runs (chain average 3.8★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleShareSince
MICHELLE WAY LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST30%since 06/01/2005
PRACTICE DYNAMICS, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST10%since 05/01/2016
LSJW LOCHEARN LLCOrganizationDIRECT OWNERSHIP INTERESTsince 06/01/2005
JEFFREY MARK ATTMAN 2005 TRUSTOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST18%since 06/01/2005
LIFEBRIDGE INVESTMENTS, INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST10%since 05/01/2016
ATTMAN, GARYIndividualINDIRECT OWNERSHIP INTEREST; CORPORATE OFFICER; ADP OF THE SNFsince 06/01/2005
ATTMAN, LEONARDIndividualCORPORATE OFFICER; ADP OF THE SNFsince 06/01/2005
FINGLASS, BRIANIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 06/01/2005
FUTURE CARE HEALTH AND MANAGEMENT CORPORATIONOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2005
MILLER, TAMARAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2022
SPADARO, JOHNIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/05/2013

CMS files one row per role, so the 18 rows in the source record cover these 11 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

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.

$28.2M
Net patient revenuemost recent cost report
+7.3%
Operating marginrevenue minus expenses
$3.8M
Related-party expense14% of expenses
Who pays — share of resident-days
Medicaid 0%Medicare 12%Other / private 88%

This home reported $3.8M paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

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

$373per resident / day
operating cost
$11,341per month
≈ monthly operating cost
$403per 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 215207. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-08, 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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