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Transitional Care Services At Mercy Medical Center

301 Saint Paul Place, Baltimore, MD 21202 · Non profit - Corporation · 35 certified beds · (410) 332-9287 Medicare & Medicaid certified

Call the home — (410) 332-9287 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Apr 2024
Insights

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

In its favor
  • 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)
  • lower-than-typical staff turnover (20% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (18) — 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 5 of 5
StaffingFrom payroll records (PBJ) 5 of 5
Quality measuresSelf-reported by the facility 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Saint Paul Place · (410) 332-9200 · Call to confirm hours
Pharmacy
301 Saint Paul St · (410) 625-2618 · Call to confirm hours
Grocery
6 E Franklin St · (443) 226-1511 · Call to confirm hours
Park
500 St. Paul · (410) 244-1030 · 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
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
Short-stay residents who newly got an antipsychotic medication1.0%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine97.5%80.6%79.4%better
Short-stay residents rehospitalized after admission27.0%21.0%22.6%worse
Short-stay residents with an outpatient ER visit5.3%9.8%12.0%better

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.

66.2% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 401 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.2%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
56.0%U.S. median 56.6%
Met the expected recovery
0.91U.S. median 0.31
Therapy hours / resident / day
0.48hours / resident / day
Physical therapy
0.42hours / resident / day
Occupational therapy
<0.01hours / resident / day
Speech therapy

Met the expected recovery: 56.0% 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 184 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 0.91 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 19% 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 SNF66.2%CMS range 63.7–69.951.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 7.0–12.610.7%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 discharge56.0%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 discharge49.5%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 discharge44.0%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 setting99.4%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 discharge97.1%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 stay0.0%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 worsened1.8%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 hospitalization4.8%CMS range 2.3–8.17.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.701.02Oct 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

2.84
RN hours/ resident / day
0.96
LPN hours/ resident / day
2.41
Aide hours/ resident / day
6.21
Total nurse hours/ resident / day
2.32
RN hoursweekends
20.0%
Total nursing turnover
22.2%
RN turnover

How full it usually is: this home is certified for 35 beds and averages 25.6 residents a day — about 73% occupied, or roughly 9 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 6.21 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 2.84 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.41 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 5.59 hrs/resident/day on weekends vs 6.46 on weekdays — 13% thinner on weekends. RN hours go from 3.05 to 2.32 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 20% is below the national median of 45%.

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

Inspection trend

4
deficiencies at the latest standard inspection (2025-11-21)
11
at the previous standard inspection (2024-04-02)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.

  • Potential for harm · E2025-11-21 · tag F0578 — failed to honor advance directives / code status — pattern
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interviews, it was determined that the facility failed to ensure the resident/responsible party was offered the opportunity to develop an advance directive for 4 (#18, #2, #12, #13) of 4 sampled residents for advance directives during the annual survey. The findings include:An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity.A Maryland MOLST (Medical Orders for Life-Sustaining Treatment) form is used for documenting a resident's specific wishes related to life-sustaining treatments. The MOLST form includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary…

    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 · D2025-11-21 · 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 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 2 (Residents #12, #9) of 4 residents reviewed for nutrition during the annual survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. 1) On 11/19/25 at 12:44 PM Resident #12's medical record was reviewed and revealed the resident was admitted to the facility on [DATE] with a weight of 90.5 lbs. There was also a weight of 104 lbs. documented in the medical record from 10/28/25, the date of discharge from the acute care…

    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 before2025-11-21 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined that the facility staff failed to ensure a resident had a baseline care plan created and initiated within 48 hours of admission to the facility. This was evident for 1 (Resident #12) out of 12 residents reviewed during the annual survey. The findings are:The baseline care plan is given to residents within 48 hours of their admission and details a variety of components of the care that the facility intends to provide to that resident. In addition to the baseline care plan, residents are also expected to receive a list of their admission medications. This allows residents and their representatives to be more informed about the care that they receive.On 11/20/25 at 1:04 PM a review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included, but were not limited to, a new diagnosed NET of liver, COPD, hypertension, and ambulatory dysfunction. Liver NET refers to neuroendocrine tumor…

    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 · D2025-11-21 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility staff failed to thoroughly assess and monitor residents at risk for weight loss. This was evident for 3 (Resident #9, #36, #12) of 4 residents reviewed for nutrition during an annual survey.The findings include: 1) Review of Resident #9's medical record on 11/19/25 revealed the Resident was admitted to the facility on [DATE] and the facility staff documented the Resident's weight to be 169 pounds. Further review of Resident #9's medical record revealed the Resident was assessed by Dietitian #1 on 11/4/25 and documented the Resident had Nutrition Diagnosis #1 Moderate acute disease or injury related to malnutrition and Nutrition Diagnosis #2 Inadequate oral intake. Dietitian #1 documented the Resident will be High and re-evaluated every 5-7 days. At that time Dietitian #1 recommended supplements. Further review of Resident #9's medical record revealed Dietitian #1 assessed the Resident on 11/7/25 and recommended adding some preferred foods to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-04-02 · tag F0657 — failed to keep the care plan current — pattern
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, and interview, it was determined the facility staff failed to: 1) review and revise resident care plans to reflect accurate and current interventions, and 2) ensure the full interdisciplinary team including residents and/or their responsible parties were invited to the care plan meetings and 3) have care plan meetings for residents who had been in the facility 21 days or more. This was evident for 4 (#4, #12, #13, #15) of 27 residents reviewed during a recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Tube feeding is a way of getting your body the nutrition it needs. Tube feed is a liquid form of food that's carried through your body through a flexible tube (feeding tube). The nutrients within the tube feed are similar to what you would get from normal food. They are also digested in the same way. Tube feeds contain…

    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 · D2024-04-02 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined the facility staff failed to treat each resident in a dignified manner by: 1) leaving a breakfast tray in the resident's closet, 2) leaving urinals hanging on the trash can in the resident's room, and 3) serving breakfast on a bedside table that had a urinal containing urine. This was evident for 2 (Resident #4, #12) of 27 residents reviewed during the survey. The findings include: 1) During an initial observation of Resident #4 on 3/25/2024 at 8:45 AM, surveyor observed a breakfast tray dated 3/25/2024 and pillows in two transparent bags in the resident's closet. NPO (nothing by mouth) signage was noted on the resident's room door. Resident #4 stated s/he did not know why and/or who placed the breakfast tray in the closet. On 3/25/2024 at 8:55 AM, the charge nurse, Registered Nurse (RN #17) was notified of surveyor's observation. RN #17 went into Resident #4's room and validated surveyor's findings. RN #17 stated the pillows in the two transparent bags were extra pillows. RN #17 further stated that the breakfast tray should not…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    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 interviews it was determined that the facility failed to maintain a comfortable homelike environment as evidenced of a resident having stained ceiling tile, rust near the trim in a resident's bathroom, fluid stains on the wall in a resident's room, and damaged drywall in a resident's room. This deficient practice was evidenced in 4 rooms of 8 rooms assessed for a homelike environment during the survey. The findings include: On 03/25/24 at 8:39 am during observation rounds upon entering room [ROOM NUMBER] the surveyor observed a stained ceiling tile in the resident's room. Nursing Tech #11 confirmed the surveyor's findings. On 03/25/24 at 8:46 am the surveyor observed discolored tile behind the commode near the trim in room [ROOM NUMBER] bathroom. Director of Nursing #2 confirmed the surveyor's findings. On 03/25/24 at 9:18 am during observations rounds Resident # 8 was in their room sitting in the chair. The surveyor observed the drywall behind the chair was damaged. Administrator #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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative (RP) in writing of a transfer/discharge of a resident along with the reason for the transfer and failed to send a copy to the ombudsman. This was evident for 2 (#7, #17) of 2 residents reviewed for hospitalization during a recertification survey. The findings include: 1) Review of the medical record for Resident #7 on 4/1/2024 at 12:00 PM revealed Resident #7 was originally admitted to the facility on [DATE] from the hospital. Further review of the medical record revealed that Resident #7 was transferred back to the hospital emergency department (ED) on 2/24/2024 for a change in mental status. However, there was no documentation and/or evidence in the record indicating that the facility staff notified the resident/resident's representative (RP) in writing of the reason for the transfer/discharge to the acute care facility on the above date/time the resident was transferred out.…

    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 · D2024-04-02 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed-hold policy upon transfer of a resident to an acute care facility. This was evident for 2 (#7, #17) of 2 residents reviewed for hospitalization during a recertification survey. The findings include: The bed-hold policy describes the facility's policy of holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization. 1) Review of the medical record for Resident #7 on 4/1/2024 at 12:00 PM revealed Resident #7 was originally admitted to the facility on [DATE] from the hospital. Further review of the medical record revealed that Resident #7 was transferred back to the hospital emergency department (ED) on 2/24/2024 for a change in mental status. Medical record documentation revealed that Resident #7's responsible party (RP) was notified of the transfer via telephone, however, there was no 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    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 record review and interview it was determined that the facility failed to provide person centered Activities that incorporated the resident's interests. This deficient practice was evidenced in 3 (#8, #13, and #170) of 3 residents who verbalized they didn't know the facility offered Activities. The findings include: On 03/25/24 at 1:38 pm during an interview with Resident #13, he/she verbalized the facility does not offer Activities. Nobody told him/her that they have Activities for the patients. 03/26/24 09:40 am during an interview with Resident #170 he/she verbalized not knowing the facility offered Activities. On 03/26/24 at 9:55 am during an interview with Resident #8 he/she verbalized not being aware if the facility offers Activities for them. On 03/28/24 10:48 am during an interview with Patient Service Representative #18 who verbalized they do not have Activities at this time. On 03/28/24 10:57 am During an interview with Administrator #1 who reported they have volunteers 3 times a week who can…

    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 8 citations
  • Potential for harm · D2024-04-02 · tag F0803 — failed to meet residents' dietary needs — isolated
    Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident, and staff interviews, it was determined that the facility failed to develop, prepare, and distribute menus that reflect a resident's nutritional wishes. This was evident for 1 (#7) of 27 residents in the facility reviewed during a recertification survey. The findings include: In an interview with Resident #7 on 3/25/2024 at 1:31 PM, the Resident stated that the food was not for me because I don't eat meat, but they serve me food with meat. Resident #7's sister who was present in the room confirmed that the resident is a vegetarian, but they keep giving him/her meat products. Resident #7 added that s/he has seen the dietitian once since being in the facility. On 3/29/2024 at 11:59 AM a surveyor observed Resident #7 sitting in a chair in front of the nurses' station with his/her lunch tray. The surveyor asked Resident #7 if s/he was going to eat his/her lunch. Resident #7 replied, No, it's terrible, and I'm a vegetarian and they keep giving me meat. The surveyor observed chopped chicken and carrots on Resident #7's lunch tray and the resident's meal…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews it was determined that the facility staff failed to use safe food practices while preparing lunch trays for the Transitional Care Unit and failed to store edible produce in the produce refrigerator located in the kitchen. This deficient practice was discovered during the survey. The findings include: On 03/25/24 at 12:51 pm during the initial walk through of the kitchen, the surveyor observed molded zucchini and squash in a box on the bottom shelf located on the right side of the produce refrigerator. There was a large plastic bag of wilted lettuce next to the box of molded vegetables. Chef #15 and Dietary Manager #15 were present when the surveyor discovered the spoiled food. On 03/29/24 at 11:18 am while in the kitchen, the surveyor observed Food Server/Menu Concierge #24 preparing lunch plates for the Transitional Care Unit. While plating the food he/she went into the under carriage with the same gloves that he/she used to plate the patient's food. Chef #15 was made aware. On 03/29/24 at 11:26 pm the surveyor observed Food Server/Menu…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · 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 observation, medical record review, and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. Furthermore, the facility staff failed to assure the completeness and accuracy of documentation related to the route of medication administration. This was evident for 1 (Resident #4) of 27 residents reviewed during the recertification survey. The findings include: On 3/25/2024 at 8:45 AM, an initial observation was made of Resident #4 in their room. The resident was lying in bed, awake, alert, and oriented to person, place, time, and situation. Resident #4 had a gauze dressing to the left upper quadrant of the abdomen and stated that s/he had a feeding tube that was discontinued. On 3/29/2024 at 10:39 AM, a review of active orders for Resident #4 revealed the following orders: Doxepin (Sinequan) capsule 25 mg: 25 mg J-Tube, daily, First dose (after last modification) on Sun 3/10/24 at 0900. Doxepin is a medication used to treat depression and other related disorders. Jejunostomy tube…

    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 · D2024-04-02 · 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 observations and interviews it was determined that the facility staff failed to maintain infection control practices as evidenced by urinals hanging over residents' trash cans, a resident's wound vac machine was on the floor, and a urinal was on the bedside table near a resident's water and food tray. This was evident for 3 (Resident #170, #15, #171) of 27 residents reviewed during the survey. The findings include: On 03/25/24 at 8:24 am during observation rounds the surveyor observed a partially filled urinal hanging over the trashcan in Resident # 170's room. The surveyor also observed Resident #170's wound vac was on the floor near the end of the bed on the right side. Quality Assurance Director #4 confirmed the surveyor's findings. On 03/25/24 at 8:42 am while speaking to Resident #15 in his/her room the surveyor observed a leg brace on the floor in front of the chair and a urinal on the bedside table next to 2 cups of water and the breakfast tray. Nursing Tech #11 confirmed the surveyor's findings. On 03/25/24 at 9:11 am During observation rounds while the surveyor 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · tag F0908 — failed to keep essential equipment working — isolated
    Keep all essential equipment working safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and record review it was determined the facility staff failed to ensure the dishwasher reached the final rinse temperature of 180' Fahrenheit. The findings include: On 03/25/24 at 1:01 pm while in the kitchen the surveyor asked Dietary Manager #13 to run the dishwasher to assess the final rinse temperature. The surveyor heard the dishwasher making a loud noise and the final rinse maximum temperature was 132' Fahrenheit (F). Patient Service Manager #15 verbalized the machine was down before it was tuned on and it needed time to reach the required temperature. He/she also verbalized the machine was making noise. Dietary Manager #13 verbalized the dishwasher was broken. On 03/25/24 at 1:04 pm the surveyor received a copy of the Dish Machine Temperature Log as requested. A brief review of the temperature log revealed the last documented final rinse temperature was 135'F on 03/25/24 at 11:00 am. On 03/25/24 at 2:10 pm further review of the Dish Machine Temperature Log revealed at least one shift during the entire month of March 2024, the final rinse temperature did…

    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
  • Potential for harm · D2024-04-02 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interviews with facility staff it was determined the facility failed to report allegations of abuse in a timely manner. This was found to be evident for 1 (Resident # 24) of 1 abuse complaint reviewed during the survey. Findings include: MD00199041 was reviewed offsite on 3/28/24 at 1:30 PM regarding abuse allegations made by Resident #24. Abuse was unsubstantiated. Continued review of the facility's investigation included a signed typed statement by the nurse, (Staff # 25), in which the resident's sitter (Staff #32) reported to the nurse on 10/27/23 that the resident accused the sitter of having her way with him/her, when she pulled the blanket down around the resident's knee area. The sitter told the nurse that she did not want to take care of the resident anymore and did not want to return to the resident room. During an interview with the Administrator on 3/29/24 at 8:37 AM she was asked who has the responsibility of conducting the facility's investigation into abuse allegations and she stated that she does investigations. She was asked to read…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-02 · 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 interviews with facility staff it was determined the facility failed to ensure that a care plan was initiated to address the specific needs of a resident with a history of sexual assault allegations. This was found to be evident for 1 (Resident # 24) of 1 abuse complaint reviewed during the survey. Findings include: MD00199041 was reviewed offsite on 3/28/24 at 1:30 PM regarding abuse allegations made by resident # 24. Abuse was unsubstantiated. A copy of a hospital history and physical (H&P) dated 10/24/23 for Resident # 24 was provided to the survey team on 3/29/24 at 9:40 AM. Upon review of the contents, it revealed information that the resident presented from outside hospital on 9/28 for sexual assault forensic exam. During an interview with the Administrator on 3/29/24 at 1:40 PM she stated that the resident came from another facility and the resident made an allegation of abuse by staff while there. The Administrator went on to say that the allegation was because heme (blood) was found in the resident undergarment, but it was later determined…

    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 before2019-05-08 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #2) of 19 residents reviewed during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #2's medical record on 5/8/19 revealed Resident #2 was readmitted to the facility on [DATE]. Review of Resident #2's medical record failed to reveal documentation that a copy of the baseline care plan was provided to Resident #2 or Resident #2's responsible party within 48 hours after admission. In an interview with the facility Director of Nursing (DON) on 5/8/19 at 12:46 PM the DON stated that the facility does not give hard copies of the resident's care plan to either the resident nor 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

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
MERCY MEDICAL CENTER INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 03/13/1996
MERCY HEALTH SERVICES INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTEREST100%since 05/20/1999
SCHWARZMANN, JENNIFERIndividualCORPORATE DIRECTORsince 01/01/2015
DEIBEL, JUSTINIndividualCORPORATE OFFICERsince 01/01/2014
CHASE, MICHELEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/01/2020
LIMPUANGTHIP, ANDREAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/01/2020

CMS files one row per role, so the 8 rows in the source record cover these 6 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.

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 215283. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-11-21, 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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