North Oaks Communities
725 Mount Wilson Lane, Baltimore, MD 21208 · For profit - Individual · 37 certified beds · (410) 602-0302 Medicare only — no Medicaid
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — 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)
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0610) — 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 (26) — 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)
- about 20% of its spending goes to commonly-owned related companies
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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 1 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
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 | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 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 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 26.2% | 20.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.5% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 2.2% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 22.8% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 11.0% | 2.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 27.0% | 22.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.0% | 16.7% | 18.9% | worse |
| Long-stay residents with pressure ulcers | 2.2% | 5.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 35.9% | 25.0% | 21.2% | worse |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 16.7% | 13.8% | 17.1% | typical |
| Short-stay residents who newly got an antipsychotic medication | 6.1% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 81.0% | 80.6% | 79.4% | typical |
| Short-stay residents rehospitalized after admission | 30.9% | 21.0% | 22.6% | worse |
| Short-stay residents with an outpatient ER visit | 6.4% | 9.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.92 | 1.33 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.53 | 1.20 | 1.80 | worse |
* 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.
22.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 0.80 therapist hours per resident per day in 2026Q1 — more than 94% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 21% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 22.7%CMS range 13.3–38.7 | 51.5% | Oct 2022–Sep 2024 | worse than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.4%CMS range 7.9–18.8 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | not 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 discharge | not 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 discharge | not 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 identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | not 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not 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 SNFs | 1.09 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 37 beds and averages 23.7 residents a day — about 64% occupied, or roughly 13 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. 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 3.94 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.08 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 3.64 hrs/resident/day on weekends vs 4.06 on weekdays — 10% thinner on weekends. RN hours go from 1.72 to 1.39 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 48% 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
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.
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.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · Fcited before2025-11-20 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
Based on observation during the initial tour of the main kitchen with facility staff it was determined that the facility staff failed to store food items in a manner that maintains professional standards of food service safety and prepare food under sanitary conditions. The findings include: On 11/17/25 at 8AM, a tour of the kitchen with the Food and Beverage Director revealed the following: 1. Grease was layered on the tiled baseboards and on every wall edge in the kitchen. 2. The freezer and refrigerator floors with blacken areas and the area was littered with debris. 3. The handwashing sinks were blocked with trash cans. 4. The ceiling tiles were noted with areas of brown stains throughout the kitchen. 5. Tiles missing from the floor at the door entrances and noted to be filled with dirt and debride. 6. The dishwasher aide had long shoulder length hair and no hair net. 7. The freezer had ice buildup on the ceiling and on an unopen box of food. 8. The Jell-O was uncovered in the refrigerator and undated. 9. Shredded mozzarella cheese in a container covered with plastic wrap with…
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.
- Potential for harm · D2025-11-20 · tag F0638 — isolatedAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, the facility staff failed to assess a resident using the standardized Quarterly Review assessment tool at least once every three (3) months between comprehensive assessments (resident #18). This was evident for 1 out of 19 residents reviewed while completing the facility assessment facility task for the facility's annual survey. Findings include: The annual survey team reviewed resident #18's medical records on 11/19/25 at 12:45pm to complete the facility assessment facility task for the facility's annual survey. The medical record revealed that the resident was overdue for a quarterly assessment. The quarterly assessment was due on 10/14/2025. The annual survey team interviewed MDS Coordinator #5 on 11/20/25 at 8:45am regarding the facility's failure to complete resident #18's quarterly assessment on 10/14/2025. MDS Coordinator #5 acknowledged that the facility failed to complete the quarterly assessment timely. MDS Coordinator #5 stated that he/she started the position on 10/13/2025 and he/she was unaware that resident #18 would have…
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.
- Potential for harm · D2025-11-20 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a revisit of previous annual surveys and deficient practices identified during this survey, it was determined that the facility failed to have an effective Quality Assurance Program as evidenced by the identification of repeat deficiency. The failure to identify and develop appropriate plans of correction to correct quality deficiencies places all residents at risk.The findings include: The repeat deficiencies reviewed included area of store, preparation, distribute, and serve food in accordance with professional standards for food service safety. The repeated deficiencies were noted in 2019, 2024 and 2025 with Severity and Scope Grid listed as an F. On 11/20/25 at 10 AM, the concerns regarding repeat deficiencies and the failure of the previous plan of correction to address issues with the QA process were discussed with the Administrator, who acknowledged the surveyor's concerns. The Administrator stated that a surprise observation of the kitchen on 10/30/25, by the of the Certified Dietary Manager revealed the same repeated issue of undated, and uncovered food. 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.
- Potential for harm · Fcited before2024-07-22 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
Based on observations and staff interview, it was determined that the facility failed to store cold foods in a safe manner and failed to ensure staff had access to proper hand washing facilities. This practice was evident for multiple areas of the main kitchen during the initial kitchen tour and had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: During observation rounds of kitchen on 7/18/24 at 8:15 AM, the initial kitchen tour was conducted by Dietary Manager (Staff #5). During initial observation, the kitchen was noted to have a stream of clear drainage coming from the dishwashing area. Upon closer observation, a pipe from underneath the manual dishwashing station was leaking. Both handwashing stations in the main kitchen did not have working paper towel and soap dispensers. One freezer temperature was not at an appropriate temperature at 8:30 AM on 7/18/2024. The freezer next to stoves and ovens closer to the dishwashing station was at 42 degrees F. This freezer contained a 3 of bags of what appeared to be breaded…
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.
- Potential for harm · Dcited before2024-07-22 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review and staff interview, it was determined that the facility failed to maintain accurate medical records on each resident. This was evident for 1 (resident #19) out of 8 residents that were reviewed during the survey. The findings include: On 07/18/24 at 9:30 AM the facility submitted a Matrix Roster to the survey team for review. The matrix roster revealed that Resident #19 was not on palliative care. Review of Resident #19 medical record on 07/19/24 at 10:15 AM revealed a Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form dated 03/27/2024. The MOLST form stated that Resident #19 was a [name of hospice provider] patient. Further review of Resident #19's record revealed that [name of hospice provider] was a hospice company that provides palliative care. During an interview on 07/19/24 at 11:00 AM the Director of Nursing (DON), Staff #3, verified the Matrix Roster that was given to the survey team was incorrect, Resident #19 was on palliative care patient.
- Potential for harm · D2024-07-22 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
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 observations and staff interviews, it was determined that the facility failed to have an effective pest control plan so that the facility is free of mice. This was evident on the [NAME] ridge unit of the facility. The findings include: During observation rounds on 07/19/2024 at approximately 9:15 AM the Director of Nursing (DON) was standing outside in the facility hallway in front of room [ROOM NUMBER], a resident's room. While the DON was standing in this location, a mouse was observed running on the floor out of room [ROOM NUMBER], stopped at the DON's feet, and ran back into room [ROOM NUMBER]. During an interview on 07/19/2024 at 9:25 AM resident #2 stated that there were mice in his/her room and there have been many mice in his/her room. During an interview on 07/19/2024 at 9:28 AM staff #14 stated that a mouse pad was placed down in room [ROOM NUMBER]'s floor, and this is what the facility had been doing for the mouse problem. During an interview on 07/19/2024 at approximately 9:39 AM staff #15…
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.
- Potential for harm · D2024-07-22 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure 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 — the official record, unedited, may be distressing
Based on review of facility documentation and interviews, the facility failed to provide the required 12-hour minimum yearly in-service training for nurses' aides. This was evident in 1 out of the 5 employee records that were reviewed during the survey. The findings include the following: Review of Geriatric Nursing Assistant (GNA) #20 employee record on 07/22/2024 at 09:45 AM revealed a hire date of 06/28/2022. The GNA #20 was still employed by facility and there was no documentation that the required 12-hour minimum yearly in-service training was completed by GNA #20 for the year 2023. During an interview on 07/22/2024 at 10:15 AM, the facility's Human Resource Director #19, stated that she was unable to provide documentation that GNA #20 completed the required 12-hour minimum yearly in-service training for the year 2023.
- Potential for harm · Fcited before2019-10-15 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure 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
Based on observations of the facility's kitchen and food services, it was determined that the facility failed to maintain food service equipment in a manner that ensured sanitary food service operations and failed to utilize appropriate hair restraints for employees in accordance with professional standards for food service safety. Concerns were identified during multiple observations of the facility's kitchen and food services operation. The findings include. An initial tour of the kitchen was initiated on 10/8/19 at 8:50 AM. At 09:50 AM, observation of the dish wash machine revealed that the wash temperature was not reaching a minimum of 160 degrees Fahrenheit. The Director/Executive chef was alerted, and he confirmed that the wash temperature gauge was stuck at 137 degrees Fahrenheit. The Director/Executive chef had instructed the dishwasher person (Staff #6) to hand wash all dishware in the three-compartment sink. The executive chef had demonstrated and tested the sanitation level in the three-compartment sink to be incompliance of at least 200 parts per million. 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.
- Potential for harm · E2019-10-15 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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 during the survey it was determined the facility failed to maintain a clean and comfortable environment. The findings include: An environmental tour was conducted with the Plant Operations Manager and the Director of Housekeeping on 10/11/19 at 1:32 PM and the following concerns were pointed out and discussed: The shower room had broken and cracked tile on the left shower wall that was in the second shower stall. There was also a black, orange and pink substance in the tile grout in the second shower stall on the walls and floor. There was a mound of debris in the corner on the floor behind the door. There was a soiled plastic glove on the floor in the corner of the right alcove. In room [ROOM NUMBER] the under the sink cabinet was dirty with black debris inside on the bottom of the cabinet and the front doors on the corner were missing laminate in addition to the laminate peeling off the particle board. In room [ROOM NUMBER] and #25 the topcoat of drywall was missing…
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.
- Potential for harm · D2019-10-15 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and resident interview it was determined that the facility staff failed to ensure that a resident had access to turn the over the bed light on and off. This was evident for 1 of 6 residents (Resident #15) interviewed during the initial phase of the survey. The findings include: An interview was conducted with Resident #15 on 10/8/19 at 9:55 AM. During the interview the over the bed light cord was observed hanging down behind the resident's bed. The resident was sitting upright in the bed and the light cord was approximately 4 feet away from the front of the resident. The resident was asked if he/she would like the ability to turn the light on and off the resident stated, Oh, I didn't realize that I could do that. The surveyor turned on the light and the resident stated, I am partially blind, but that makes it so much brighter in here. The surveyor asked the resident if he/she would like the surveyor to say something to Administration and the resident stated that he/she wanted to be able to have a longer cord. On 10/11/19 at 1:00 PM the surveyor toured 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.
Show the remaining 16 citations
- Potential for harm · D2019-10-15 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility documentation and interview with facility staff it was determined the facility failed to have evidence that an allegation of missing property was thoroughly investigated. This was evident for 1 of 2 residents (Resident #12) reviewed for Abuse. The findings include: A review was conducted of Facility reported incident #MD000142875 on 10/9/19 in which a family member reported that Resident #12 was missing a gold wedding band. The facility's investigative documentation included a statement from the resident's family member who felt someone must have forcefully removed the ring, review of a report from a bruise on the resident's hand from 7/8/19 and a search of the resident's room. The investigation indicated that security camera footage from 6/30/19 6:30 PM to 9:30 AM on 7/1/19 and from 7/7/19 6:30 PM to 9:30 AM on 7/8/19 was reviewed based on the time frame the resident's family member thought the ring may have gone missing. The facility was unable to reach a conclusion. Resident #12 had Private Duty Assistants (PDA's) during the day and evening however 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.
- Potential for harm · D2019-10-15 · tag F0641 — isolatedEnsure 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 Minimum Data Set (MDS) assessments were accurately coded. This was evident for 3 of 15 residents (Resident #5, #15, and #6) reviewed during the 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) A review of the medical record for Resident #5 was conducted on 10/10/19 which included a review of Medication Administration Records (MAR). Review of the January 2019 MAR documented that the resident received the medication Tramadol (an analgesic that contains an opioid) and Ativan (anti-anxiety). Review of the MDS assessment with an assessment reference date (ARD) 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.
- Potential for harm · D2019-10-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop 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, observation and staff interview it was determined the facility failed to follow person-centered care plans. This was evident for 1 of 3 residents (Resident #5) reviewed for a skin condition and 1 of 1 resident (Resident #6) reviewed for accidents. 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. 1) Review of Resident #5's medical record on 10/8/19 revealed October 2019 physician's orders, bilateral upper extremities geri-sleeves on at all times except ADL (activities of daily living) care. A review of Resident #5's care plan, Actual skin impaired had the intervention, skin sleeves as tolerated at all times and keep hand sleeve in place. Observation was made on 10/8/19 at 11:37 AM of Resident #5 in activities, sitting in a geriatric (geri) chair. The resident did not have geri-sleeves on. The resident was observed again on 10/8/19 at 2:37 PM in a music activity sleeping in the chair. The resident was wearing a yellow/mustard…
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.
- Potential for harm · D2019-10-15 · tag F0657 — failed to keep the care plan current — isolatedDevelop 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 staff interview it was determined that the facility failed to show that a care plan was evaluated and revised by the interdisciplinary team after an assessment. This was evident for 1 of 1 resident (Resident #6) reviewed for accidents. 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. Resident #6's medical record was reviewed on 10/9/19. A review of Resident #6's care plan, revealed that a care area for Fall risk was initiated on 3/20/19. The goal for this plan of care was written as; [name of resident] will maintain current level of mobility with no increase in the incidence of falls/inquires. The last quarterly Minimum Data Set (MDS) assessment had an assessment reference date of 7/22/19. A care plan meeting was held on 7/31/19 per a social worker note. An evaluation of the falls plan of care was not found in the medical record. On 10/10/19 at 4:57 PM an interview was held with the MDS coordinator, Staff #4 specifically…
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.
- Potential for harm · D2019-10-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation and staff interview, it was determined the facility failed to render care in accordance with the resident's care plan and failed to apply an ordered treatment. This was evident for 1 of 3 residents (Resident #5) reviewed for a skin condition. The findings include: Review of Resident #5's medical record on 10/8/19 documented that the resident had frequent skin tears. A CRNP (Certified Registered Nurse Practitioner) note of 8/12/19 documented, Seen for ongoing medical follow-up. Nursing reports that pt (patient) has a skin tear to LLA (left lower arm) and is not healing well. A treatment was ordered. A review of Resident #5's care plan, Actual skin impaired had the intervention, skin sleeves as tolerated at all times and keep hand sleeve in place. The care plan evaluation that was done on 10/9/19 documented, resident had a skin tear to left lower arm in August 2019. Area was treated with bacitracin. Treatment to arm was resolved and treatment was discontinued. Resident continues with Geri-sleeves. Staff applies Geri-sleeves and assist with…
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.
- Potential for harm · D2019-10-15 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolatedProvide appropriate pressure ulcer care and prevent new ulcers from developing.
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 thoroughly assess a pressure ulcer consistent with professional standards of practice and promote healing to a pressure ulcer. This was evident for 1 of 1 resident (Resident #19) reviewed for pressure ulcers. The findings include: Review of Resident #19's medical record on 10/9/19 revealed that on 9/16/19 a nurse documented in a progress note .a new open skin area was noticed on right buttock. The new open area is a stage 2 decubitus which measures 2 cm (centimeters) x 1.5 cm x 0.1 cm. The note indicated that the wound was cleansed and Lanaseptic cream was applied. Additionally, the nurse's note indicated that the resident's attending physician was at the facility to see the resident. There was not any documentation from the resident's attending physician related to seeing the resident on 9/16/19. There was not a physician order for the application of Lanaseptic cream/ointment. Review of the physician orders revealed a standing order dated 8/28/19 for calmoseptine cream to excoriation in…
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.
- Potential for harm · D2019-10-15 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure 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 staff interview, it was determined the facility failed to provide a physician order safety device that was in accordance with the resident's care plan. This was evident for 1 of 1 resident (Resident #6) reviewed for accidents. The findings include: Review of Resident #6's medical record on 10/9/19 revealed October 2019 physician's orders, floor mat to right side of bed when in bed q (every) shift. This order was initiated on 4/9/19. A review of Resident #6's care plan, revealed that a care area for Fall risk was initiated on 3/20/19. On 4/11/19 the following intervention was added: Place fall mats next to right side of bed while resident in bed. An interview was conducted with Resident #6 on 10/9/19 at 8:51 AM while the resident was still in bed. A mattress was observed standing on end against a wall. The resident was asked about the mattress up against the wall and s/he responded that they usually put it down at night. On 10/10/19 at 8:55 AM, Resident #6 was observed to be in bed without a fall mattress on the floor next to 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.
- Potential for harm · D2019-10-15 · tag F0710 — isolatedObtain 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 a medical record review, it was determined that a physician failed to fully evaluate a resident as related to facility acquired pressure ulcers. This is evident for 1 of 1 resident (Resident #19) reviewed for pressure ulcers. The findings include: Review of Resident #19's medical record on 10/9/19 revealed this resident had acquired pressure ulcers while in the facility. A nurse's progress note written on 9/16/19 stated: .a new open skin area was noticed on right buttock. The new open area is a stage 2 decubitus which measures 2 cm (centimeters) x 1.5 cm x 0.1 cm. The note indicated that the wound was cleansed and Lanaseptic cream was applied. Additionally, the nurse's note indicated that the resident's attending physician was at the facility to see the resident. There was not any documentation from the resident's attending physician related to seeing the resident on 9/16/19. There was not a physician order for the application of Lanaseptic cream/ointment. Review of the physician orders revealed a standing order dated 8/28/19 for calmoseptine cream to excoriation in groin…
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.
- Potential for harm · D2019-10-15 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review it was determined the facility failed to ensure Certified Registered Nurse Practitioner (CRNP) medical visit notes were in the resident medical record on the day the resident was seen. This was evident for 1 of 1 resident (Resident #19) reviewed for pressure ulcers. The findings include: A review of the medical record for Resident #19 on 10/9/19 revealed multiple occasions when the CRNP failed to document in the resident's medical record on the day of the visit. (A CRNP is an advanced practice nurse who performs the functions of a physician.) A CRNP note by (Staff #7) with 8/12/19 as the date of service (DOS) was shown to have been faxed to the facility on 9/26/19. Another example of a late CRNP note with 8/16/19 as the DOS was shown to have been faxed to the facility on 9/18/19. The last CRNP note in the resident's record on 10/9/19 had a date of service as 8/29/19 and the note was faxed to the facility on 9/12/19. Copies of the late notes were obtained from the Director of Nursing as she was informed of the concern on 10/10/19.
- Potential for harm · D2019-10-15 · tag F0744 — failed to care for residents with dementia — isolatedProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
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 the facility staff failed to provide a resident centered dementia treatment and services plan by failing to create and implement resident centered care plans with achievable goals, measurable objectives and evaluations related to daily activities. This was evident for 1 of 2 residents (Resident #9) reviewed for dementia care. 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. 1) Review of the medical record for Resident #9 on 10/11/19 documented that the resident had a BIMS (Brief Interview of Mental Status) of 8 on the most recent Minimum Data Set assessment with an assessment reference date of 8/15/19. A BIMS coded between 0 and 7 indicates severe cognitive impairment, scores between 8 and 12 indicate moderate impairment while scores above 13 shows little to no impairment. The evaluation is used to detect cognitive impairment and is a quick snapshot for that time. Further 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.
- Potential for harm · D2019-10-15 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 review of the medical record and interview with facility staff it was determined the facility's consulting pharmacist failed to identify and refer to the physician a discrepancy in medication orders. This was evident for 1 of 1 resident (Resident #17) reviewed for Pain Management. The findings include: Resident #17's medical record was reviewed on 10/9/19 at 12:43 PM. A review of the resident's MAR (Medication Administration Record) revealed a physician's order for Prednisone 2.5 mg (milligram) tablet (3 tabs(75 mg)) every day starting 3/22/19 for Chronic pain syndrome. Notes: 3 tabs = 75 mg. 3 tablets of 2.5 mg strength would equal 7.5 mg not 75mg as written. Review of the physician's orders in the EMR (Electronic Medical Record) revealed the physicians order for Prednisone also indicated 2.5 mg 3 tabs = 75 mg. Review of the paper record on 10/10/19 at 9:08 AM revealed a printed physician's order dated 3/12/19 for Prednisone tab 2.5 mg Administer 3 tablets 7.5 mg by mouth one time a day. The Director of Nursing (DON) was present at that time and indicated that the paper…
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.
- Potential for harm · D2019-10-15 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure 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 review of the medical record and interview with facility staff it was determined the facility failed to ensure each resident's drug regimen was free from unnecessary drugs. This was evident for 1 of 1 resident (Resident #17) reviewed for Pain Management. The findings include: A review of Resident #17's record was conducted on 10/10/19 at 11:53 AM. The monthly pharmacist drug regimen review log revealed that irregularities in Resident #17's drug regimen were referred to the physician during the reviews conducted on 4/15/19 and 5/15/19 however the referrals were not found in the resident's record. An interview was conducted with the DON (Director of Nursing) on 10/10/19 at 2:45 PM. She was made aware of the above findings and provided the surveyor with her copy of the pharmacists referrals. The pharmacist referral dated 5/15/19 identified that the physician had started Resident #17 on Levothyroxine (Synthroid) in response to another resident's TSH (Thyroid Stimulating Hormone) lab results which had been filed in Resident #17's record in error. Synthroid is a medication used…
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.
- Potential for harm · D2019-10-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 and staff interview it was determined the facility staff failed to label medications when opened and discard medication after being opened for longer than 24 hours for 2 of 3 medication carts and 1 of 1 treatment cart observed. The findings include: Observation was made on 10/8/19 at 11:17 AM of medication cart 1. Resident #8s opened Lantus injection 100u/ml was not dated when opened. Licensed Practical Nurse (LPN) #2 was with the surveyor at the time of observation. Observation was made of medication cart #2 on 10/8/19 at 11:20 AM. Resident #13's Novolog insulin had 2 dates opened written on the container, 8/3 and 10/3. The insulin was dispensed on 8/3/19 and one half of the bottle was missing insulin. LPN #3 was with the surveyor at the time and stated she thought the date of 8/3/19 was the correct date since half of the insulin had been used. According to the manufacturer's website Novolog is only good for 28 days once opened. Observation was made on the treatment cart on 10/8/19 at 11:25 AM. There was an opened 100 ml bottle of sterile water lot #1803049…
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.
- Potential for harm · Dcited before2019-10-15 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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 review of the medical record and interview with facility staff it was determined the facility failed to maintain complete and accurate medical records by 1) failing to ensure accuracy of the electronic physicians orders and medication administration record, 2) failing to ensure the medical record contained the consultant pharmacists recommendations, 3) failing to ensure laboratory results were filed in the correct resident record, and 4) professional nursing staff signing off that a treatment was performed when it was observed not to be done. This was evident for 1 of 1 resident (Resident #17) reviewed for Pain Management, and 1 of 3 residents (Resident #5) reviewed for a skin condition. The findings include: 1) Resident #17's medical record was reviewed on 10/9/19 at 12:43 PM. A review of the resident's MAR (Medication Administration Record) revealed a physician's order for Prednisone 2.5 mg (milligram) tablet (3 tabs(75mg)) every day starting 3/22/19 for Chronic pain syndrome. Notes: 3 tabs = 75 mg. 3 tablets of 2.5 mg strength would equal 7.5 mg not 75 mg as written.…
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.
- No harm found · C2019-10-15 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on surveyor observation and review of the facility's records it was determined the facility failed to post the required staffing information on a daily basis. This was evident for 1 of 1 nursing units. The findings include: The surveyor observed the facility's posted staffing information on 10/8/19 at 10:05 AM. The facility census on this day was 23. A staffing sheet was observed in a clear plastic frame on top of the nurses station wall. The Form did not include the facility name, the census and the total number and actual hours worked by the licensed and unlicensed nursing staff. On 10/11/19 at 10:30 AM, the surveyor reviewed the Daily staffing sheets for each shift from 10/7/19 at 7 AM thru 3 PM on 10/11/19. None of the sheets indicated the census, the total number and the actual hours worked by the licensed and unlicensed staff.
- No harm found · B2019-10-15 · tag F0559 — patternHonor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview with staff it was determined the facility failed to notify a resident/resident representative in writing of a new roommate. This was evident for 1 of 15 residents (Resident #5) reviewed during the survey. The findings include: Review of Resident #5's medical record on 10/10/19 revealed social services documentation dated 9/9/19 at 1:14 PM which stated, SW made resident and daughter aware that resident will be receiving a new roommate on 9/10/. They are understanding. Will monitor adjustment. The paper and electronic medical record was reviewed and there was no written notification of transfer found. An interview was conducted with the Social Work Director on 10/15/19 at 8:45 AM and she stated that she did not give written notice, she only gave verbal notice and she did not know anything about the regulation. The Director of Social Work came back to the surveyor on 10/15/19 at 9:32 AM and stated there was no formal policy or process for written notification, however she does sometimes communicate via email with the family. The Social Work…
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.
“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.
- 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.
Fines & penalties
No federal fines in the current CMS record.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| BSD 26 HOLDINGS LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2021 |
| IKE AKIKO | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 12/01/2021 |
| BIDERMAN, MICHAEL | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | NO PERCENTAGE PROVIDED | since 12/01/2021 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
2 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.
This home reported $2.4M paid to related parties — landlords or management companies under common ownership — equal to about 20% 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. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
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
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
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Maryland Medicaid page for homes that do.
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 215229. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-20, 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.