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Larkin Chase Center

15005 Health Center Drive, Bowie, MD 20716 · For profit - Corporation · 120 certified beds · (301) 805-6070 Medicare & Medicaid certified

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Abuse/neglect citation on record (F0600) — cited Nov 20182 immediate-jeopardy citations$127,440 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Nov 2018
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • inspectors cited 2 immediate-jeopardy problems — the most serious level
  • a high number of inspection citations overall (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $127,440 in federal fines (most recent 2026-04-14)
  • its last standard health inspection was over 4 years ago — the star rating may not reflect current conditions

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

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

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

Location & what’s nearby

Hospital
1/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
14999 Health Center Dr · (301) 805-5600 · Call to confirm hours
Pharmacy
14999 Health Center Dr Ste 201
Grocery
Safeway0.4 mi
4101 Northview Dr · (301) 262-7992 · Call to confirm hours
Park
3701 Northview Dr · (301) 809-3011 · Typically dawn to dusk
Place of worship
14909 Health Center Dr

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 fell from 4 to 3 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 rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents who lose too much weight7.7%5.4%5.4%worse
Long-stay residents with a urinary tract infection0.0%1.5%2.0%better
Long-stay residents with depressive symptoms47.8%22.8%6.5%worse than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury0.0%2.4%3.3%check this — see note marked star below the table
Long-stay residents on antianxiety or hypnotic medication7.4%16.7%18.9%better
Long-stay residents with pressure ulcers22.2%5.9%4.7%worse
Short-stay residents who newly got an antipsychotic medication0.3%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine93.3%80.6%79.4%better
Short-stay residents rehospitalized after admission16.2%21.0%22.6%better
Short-stay residents with an outpatient ER visit5.7%9.8%12.0%better

* 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.

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.

53.3%U.S. median 56.6%
Met the expected recovery
0.75U.S. median 0.31
Therapy hours / resident / day
0.36hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.15hours / resident / day
Speech therapy

Met the expected recovery: 53.3% 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 105 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 0.75 therapist hours per resident per day in 2026Q1 — more than 93% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 15% 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 SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNFnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge53.3%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 discharge45.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge53.3%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 identified97.9%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 setting97.7%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 discharge98.2%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 stay0.7%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 worsened0.0%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 hospitalizationnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFsnot reported — The data for this measure is missing or was not submitted. Call the facility to discuss this quality measure.

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

Staffing

1.23
RN hours/ resident / day
0.92
LPN hours/ resident / day
1.54
Aide hours/ resident / day
3.69
Total nurse hours/ resident / day
0.94
RN hoursweekends
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 120 beds and averages 68.6 residents a day — about 57% occupied, or roughly 51 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 3.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.23 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.54 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 3.24 hrs/resident/day on weekends vs 3.87 on weekdays — 16% thinner on weekends. RN hours go from 1.35 to 0.94 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

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

Inspection trend

7
deficiencies at the latest standard inspection (2022-06-14)
7
at the previous standard inspection (2018-11-01)

Deficiencies are unchanged from the previous inspection. 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.

This trend is not current. The most recent of these two inspections was over 4 years ago; the arrow describes what inspectors found then, not what the home is like now.

Inspection deficiencies

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

ABCDEFGHIJKL

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

25 citations, most serious first. The 12 most serious are shown; the remaining 13 are one tap away and print in full.

  • Immediate jeopardy · Jdisputed · IIDR2026-04-14 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to promptly notify the provider of a critical and abnormal laboratory test values for 1 (Resident #7) of 3 sampled residents reviewed for a change in condition. On [DATE], Resident #7 experienced a change in condition and a nurse practitioner (NP) ordered STAT (a Latin word, statim, which meant immediately or without delay) laboratory tests to rule out pneumonia and assess for other possible underlying causes of the resident's change in condition. The blood specimen was collected for the laboratory tests, which revealed the resident had a high critical sodium level of 161 millimoles per liter (mmol/L). This critical laboratory value was communicated to the facility nursing staff on [DATE]; however, the provider was unaware of the results until [DATE]. After review of the resident's clinical status and laboratory test results, concern was expressed by the providers for the resident's deterioration and agreed the resident required…

    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
  • Immediate jeopardy · Jdisputed · IIDR2026-04-14 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure a STAT (a Latin word, statim, which meant immediately or without delay) chest x-ray was completed as ordered and timely provider notification of a critical and abnormal laboratory test values for 1 (Resident #7) of 3 sampled residents reviewed for a change in condition. On [DATE], Resident #7 experienced a change in condition and a nurse practitioner (NP) ordered a STAT chest x-ray and STAT laboratory tests to rule out pneumonia and assess for other possible underlying causes of the resident's change in condition. The STAT chest x-ray was not completed on [DATE]. The blood specimen was collected for the laboratory tests, which revealed the resident had a high critical sodium level of 161 millimoles per liter (mmol/L). This critical laboratory value was communicated to the facility nursing staff on [DATE]; however, the provider was unaware of the results until [DATE]. After review of the resident's clinical status and…

    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 · E2026-04-14 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure there was an order to perform wound care when Resident #6 was identified to have an in-house acquired Stage 2 pressure ulcer. The facility further failed to ensure an order to perform wound care was transcribed and implemented for Resident #9's in-house acquired Stage 3 pressure ulcer; notify the Lead Registered Dietician of the resident's new pressure ulcer; and ensure there was not inconsistencies in how the resident's pressure ulcer was assessed and documented. These failures affected 2 (Resident #6 and Resident #9) of 3 sampled residents reviewed for pressure ulcer/injury.Findings included: A facility policy titled, NSG236 Skin Integrity and Wound Management, revised 09/15/2025, revealed PURPOSE To provide safe and effective care to promote optimal skin health, prevent injuries, and promote healing within the context of what matters most to all patients. The policy specified, 6.7 Notify interdisciplinary team members…

    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 · D2026-04-14 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to obtain consent prior to the use of psychotropic medications for 2 (Resident #6 and Resident #7) of 14 sampled residents. The findings included: 1. A Face Sheet revealed the facility admitted Resident #6 on 02/02/2026. According to the Face Sheet, the resident had a medical history that included diagnoses of anxiety disorder and primary insomnia. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS indicated the resident used an antianxiety medication during the last seven days. Resident #6's Care Plan Report included a focus area initiated 02/11/2026, that indicated the resident was at risk for complications related to the use of psychotropic drugs. Interventions directed staff to provide informed consent to resident or healthcare decision maker (initiated 02/11/2026). Resident #6's Order Recap Report for the timeframe 02/01/2026 - 03/31/2026,…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-04-14 · 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 interview, record review, document review, and facility policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident #5) of 8 sampled residents reviewed for abuse.Findings included: A facility policy titled, Abuse Prohibition, revised 11/14/2025, revealed, 7. Immediately upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the Administrator or designee will perform the following 7.1 Enter allegation into PCC [Point Click Care] Risk Management Portal. 7.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two (2) hours after the allegation is made. A Face Sheet revealed the facility admitted Resident #5 on 12/04/2025. According to the Face Sheet, the resident had a medical history that included a diagnosis of muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 02/09/2026, revealed Resident #5 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated the resident had intact…

    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 · D2026-04-14 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, document review, and facility policy review, the facility failed to ensure staff assigned to care for a resident was interviewed once the resident voiced an allegation of neglect for 1 (Resident #1) of 8 sampled residents reviewed for abuse.Findings included: A facility policy titled, OPS300 Abuse Prohibition, revised 11/14/2025, indicated 7.7 Initiate an investigation within 24 hours of an allegation of abuse that focuses on: 7.7.1 whether abuse or neglect occurred and to what extend; 7.7.2 clinical examination for signs of injuries, if indicated; 7.7.3 causative factors; and 7.7.4 interventions to prevent further injury. 7.8 The investigation will be thoroughly documented within the Risk Management Portal. Ensure that documentation of witnessed interviews is included. A Face Sheet revealed the facility admitted Resident #1 on 07/02/2025. According to the Face Sheet, the resident had a medical history that included a diagnosis of muscle weakness. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/29/2025, revealed…

    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 · D2026-04-14 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview, record review, and document review, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) for 1 (Resident #9) of 3 sampled residents reviewed for pressure ulcer/injury. Findings included: On 04/14/2026 at 8:59 AM, Clinical Advisor #32 stated the facility did not have a policy regarding completion of the MDS; however, they followed the Resident Assessment Instrument manual. The Centers for Medicare & Medicaid Services Long-Term Care [LTC] Facility Resident Assessment Instrument [RAI] 3.0 User's Manual dated 10/2024, indicated If the medical record reveals that the resident currently has a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing or device, the resident is at risk for worsening or new pressure ulcers/injuries. Per the LTC Facility RAI 3.0 User's Manual, Code 1, yes: if the resident had any pressure ulcer/injury (Stage 1, 2, 3, 4, or unstageable) n the 7-day look-back period. A Face Sheet indicated the facility admitted Resident #9 on 08/05/2025. According to the Face Sheet, the resident had a medical history…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-20 · tag F0583 — failed to protect personal privacy — isolated
    Keep residents' personal and medical records private and confidential.
    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 interviews, the facility failed to protect residents private information during medication administration. This had the potential to affect 14 of 73 residents information.During observation on 2/19/26, a medication cart was observed between rooms [ROOM NUMBERS] from 9:55 am until 9:59 am, with the Electronic Health Records visible on the computer screen for 14 of 73. Several visitors and staff members were seen walking along the hallways past the medication cart. Licensed Practical Nurse (LPN) 23 walked out of room [ROOM NUMBER], approached the medication cart, and locked it, but did not close the Electronic Health Records (EHR).During the interview on 2/19/23 at 9:59 am, LPN #23 confirmed s/he was the nurse responsible for the medication cart and that s/he had left the EHR visible, with resident information displayed.During the interview on 2/19/23 at 10:04 am, the Director of Nursing (DON) stated that the expectations are for nursing staff to protect residents' personal health…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-20 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, and review of facility policy titled 'Medication Storage-Storage of Medications', the facility failed to ensure 1 of 4 medications carts was locked when not in use.Review of facility policy titled 'Medication Storage-Storage of Medications' dated 01/25 revealed 'Procedures 3. To limit access to prescription medication, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medication (such as medication aides) may access medication carts. Medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by people with authorized access.'During observation on 2/19/26, a medication cart was observed between rooms [ROOM NUMBERS], unlocked and unattended from 9:55 am until 9:59 am. Several visitors and staff members were seen walking along the hallways past the medication cart. Licensed Practical Nurse (LPN) 23 walked out of room [ROOM NUMBER], approached the medication cart, and locked it.During the interview on…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2022-06-14 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews it was determined that the facility failed to ensure: 1) food items were stored properly and 2) staff practiced appropriate use of gloves. This deficient practice has the potential to affect all residents. The findings include: 1) During a tour conducted of the kitchen's refrigerator on 06/06/2022 at 11:50 AM, the surveyors, the District Dietary Manager # 6 and District Dietary Manager # 7 observed 1 opened and undated box of rice, 1 jar of Peanut Butter opened and undated, 1 container of ground turmeric opened and undated, 1 bag of Parmesan cheese opened and undated, and 1 bottle of Kikkoman Soy Sauce that expired on 05/15/2022. 2) During a tour conducted in the kitchen on 06/06/2022 at 12:05 PM, the surveyors and District Dietary Managers # 6 and # 7 observed Dietary Aide # 8 on the tray line. The Kitchen Aide moved empty breakfast trays down the tray line without the use of gloves. During an interview conducted on 06/06/2022 at 12:06 PM, the District Dietary Manager # 6 stated the kitchen policy required staff to wear gloves during food and…

    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 · D2022-06-14 · 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 — the official record, unedited, may be distressing

    Based on observations and interviews it was determined the facility failed to ensure resident rooms were kept in a home like environment. This was found to be evident for 2 (Resident #72 and #87) out of 8 resident rooms observed during the re-certification survey. The findings include: During a tour conducted on the 200-nursing unit on 06/07/2022 at 7:45 AM, surveyors observed Resident #87's closet door lying inside of the resident's closet. During the continued tour of the 200-nursing unit on 06/07/2022 at 7:52 AM, surveyors observed two holes in the wall above the footboard near the entry door of the bathroom in Resident # 72's room. An interview conducted on 06/07/2022 at 1:22 PM, the surveyor advised the Administrator and Director of Nursing (DON) of the observations.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-14 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, the facility failed to notify the Ombudsman and Responsible Party in writing that Resident # 75 was sent to the hospital. This was evident for 1 out of 1 resident reviewed for hospitalization. The findings include: On 6/6/22 at 12:39 AM, a medical record review was conducted for Resident # 75. The record revealed that on 1/25/22: General: Patient was admitted /readmitted for the following reason(S): Teaching and Training Nutrition management cancer Gastrointestinal disease/disorder Management of Diabetes Pain Management The pt. had been hospitalized for greater then 5 days. Additional details about this note: Resident [AGE] year old male admitted with history of rectal cancer. Status/Post (S/P) sepsis, rhabdomyolysis and AKI; Colostomy to left side of abdomen. Resident diabetic with hypertension; Accordion drain to right upper back; No known allergies. The record revealed that on 2/10/22: Resident was sent out to the hospital for further Evaluation due to low H&H, MD (Doctor) and…

    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
Show the remaining 13 citations
  • Potential for harm · D2022-06-14 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of minimum data set (MDS) assessment information and interview with facility staff, it was determined that the facility failed to transmit an MDS assessment within 14 days after completion. This was evident for 1 (Resident #1) of 1 resident reviewed for the Resident Assessment. The findings include: The MDS is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments are completed at differing intervals but never further than 92 days apart as long as a resident remains at a facility. Each assessment must be encoded within seven days and transmitted within fourteen days of the assessment being performed. On 6/10/22 at 9:40 AM, the surveyor reviewed information from the Centers for Medicare and Medicaid Services (CMS) regarding transmission of MDS assessments for the facility. The review revealed that no assessment information had been transferred for Resident #1 from the facility CMS in over 120 days (and that no…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-14 · 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 — the official record, unedited, may be distressing

    Based on Medical Record Review Resident # 53 did not have a care plan written for the use of a urinary cather and multiple UTI (Urinary Tract infections). This was evident for 1 out of 1 residents. The findings include: On 06/06/22 at 01:43 PM, a medical record review was conducted for Resident # 53. The resident has a urinary catheter for stage 4 wounds. There was no C.P (Care Plan) for the use of the urinary catheter. On 3/30/22 Resident #53 went to the Wound Care Center and was ordered an indwelling Foley catheter. There was no Care Plan (C.P.) for the Foley Catheter or for the care of Foley Catheter. The Administrator was made aware of this finding by the surveyor at the survey exit.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-14 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, the facility failed to put dates on the oxygen tubing and tracheostomy tubing, and gastrostomy tubing for Resident # 100. This was evident for 1 out of 1 resident without dated tubing. The findings include: A interview was conducted with Resident # 100 on 6/6/22 at 11:10 AM. At that time, the surveyor's observation revealed that the tubing for GT (Gastrostomy Tube), Oxygen and Tracheostomy (Trach) tubing was not dated.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2022-06-14 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of insects. This was found to be evident for the kitchen. The findings include: During a tour conducted of the kitchen on 06/09/2022 at 7:00 AM, the surveyor observed the floor wet and multiple gnats that flew around the dishwasher area. On 06/09/2022 at 7:02 AM an interview was conducted; the Kitchen [NAME] #11 stated the dishwasher area had a leak in the floor but had since been fixed which had caused the gnats. During an interview conducted on 06/09/2022 at 7:15 AM, the District Dietary Manager #6 stated he/she would have maintenance address the gnat issue and floor. During an interview conducted on 06/09/2022 at 10:33 AM, the surveyor advised the Director of Nursing (DON) about her observations of gnats. The DON stated he/she would have the Maintenance Director look into the gnats and floor of the kitchen.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2018-11-01 · tag F0583 — failed to protect personal privacy — pattern
    Keep residents' personal and medical records private and confidential.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medication cart observations and staff interviews it was determined that facility staff failed to ensure that medical records were kept in a confidential manner. This was evident in 2 out of 2 medication carts involving Resident's (R#10, R#14, R#28, R#93 and R#120). The findings include: On 10/31/18 at 9:30 A.M. the surveyor observed on the Southside wing unit, on top of a standing unattended Team #3 medication cart, the nurses shift to shift report document that was not kept in a confidential manner. The document is used by the facilities nursing staff for assigning nursing tasks preformed during the nurses shift with assigned residents. On that shift to shift report the surveyor viewed resident's names, room numbers, vital signs, pain medications, labs, pain refusal with nursing medication and treatment comments visible for the public to view which involved residents (R#10, R#14, and R#93) that resided on the unit. On the same day, 10/31/18 at 9:45 A.M., during an interview with nurse staff member #3 he/she replied, I just stepped away for a minute to assist a resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2018-11-01 · tag F0623 — pattern
    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 interview with staff it was determined that the facility failed to have a system in place to ensure that residents or resident representatives were notified in writing that they are being transferred out of the facility to a hospital and the reason why the facility is transferring the resident out. This was found to be evident for 3 out of 3 residents' (Resident's #48, #81, and #92) reviewed for a complaint during the investigative portion of the survey. The findings include: 1). On October 29, 2018 at 1:40 P.M. record review revealed that Resident #48 was hospitalized on [DATE]. Interview of the Administrator and Social Service Director revealed that facility staff did not provide written documentation to the resident in writing of the time and the reason for the hospital transfer. 2). Resident #81's medical record was reviewed on 10/30/18 during the investigative stage of the survey process. It was noted that the resident was sent out to the hospital on 9/5/18. Further review…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2018-11-01 · tag F0921 — failed to keep a safe, functional, sanitary building — pattern
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — the official record, unedited, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, environmental rounds and interview with the Maintenance Director it was determined that the facility failed to maintain clean, intact walls in resident rooms. The findings include: On 10/29/2018 at 12:30 PM, surveyors observed the following damage in resident 's rooms: 1. room [ROOM NUMBER], the corner guard on wall entering the bathroom was in disrepair. 2. room [ROOM NUMBER] B, the cove base molding/wall near floor was in disrepair. 3. room [ROOM NUMBER] A, the corner guard near bathroom was in disrepair. 4. room [ROOM NUMBER] B, the interior wall next to the bathroom was in disrepair, plaster was tearing from the wall. 5. room [ROOM NUMBER] A, observed various patches of exposed drywall throughout the room near the cove base molding These findings were confirmed via interview with the Maintenance Director on 10/30/2018.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2018-11-01 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on staff interview and review of medical records and other pertinent documentation, it was determined the facility failed to ensure that Resident #73 was free of abuse from a staff member. This was evident for 1 of 47 residents reviewed during the survey. The findings include: On 10/30/18, an investigation was initiated regarding a facility reported incident involving Resident #73. According to the facility report, an Occupational Therapist (OT) came in to work one morning and observed Resident #73 in the back hallway attempting to enter a bathroom. As the OT approached the resident, she observed that the resident had been tied around his/her waist to the wheelchair. She immediately wheeled the resident to the unit and handed the resident over to the Charge Nurse. She, also, stated that she informed an Assistant Manager at the start of the day shift. According to Code of Maryland Regulations (COMAR) 10.07.09.14 Physical and Chemical Restraints: A. Physical restraints may be used only: (1) As an integral part of an individual medical treatment plan; (2) If absolutely necessary…

    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 · Dcited before2018-11-01 · 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 observation and interviews with facility staff, it was determined that food service employees failed to ensure that equipment was maintained and safe food handling practices were followed to reduce the risk of foodborne illness. The findings include: On October 26, 2018 at 9:30 AM surveyors toured the facility main kitchen with the Food Service Manager. The following observations were made: 1) Two of three hand sinks were observed with no paper towels for hand drying. 2) Metal pans were not air dried prior to storage. Air drying dishes and utensils is required to ensure adequate sanitization. 3) Three light bulbs were not functioning under the fume hood. 4) Employee ' s personal items were observed in the food prep area. Personal items should be kept separate from the food preparation area to prevent cross contamination. On October 31, 2018 at 1:45 PM, surveyors toured the facility kitchen with the Food Service Manager. The following observations were made: 1) The self-closing device on the walk in refrigerator was not functioning properly causing the door to remain ajar.…

    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 · D2018-11-01 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review and staff interview it was determined the facility failed to ensure that personal hygiene equipment items meant for individual use were not mixed together for roommates, Residents #70 and #101 and roommates, Residents #6 and #71. This was evident for 4 of 47 residents investigated during the survey. The findings include: On 10/26/18 at 10:35 AM, 4 washbasins and a fracture bedpan, some marked for bed A and some for bed B, were found stacked inside of each other in the bathroom shared by Resident #71 and Resident #6. In another bathroom shared by Residents #101 and #70, 2 washbasins labeled as bed A, 3 wash basins marked bed B, and an unmarked fracture pan were stacked inside each other. Infectious organisms (e.g., bacteria, viruses, or parasites) may be transmitted by direct contact (e.g., skin.-to-skin) or indirect contact (e.g., inanimate objects). Resident care equipment that is moved from resident to resident may serve as a vehicle for transferring infectious organisms if the object is contaminated. The facility is responsible to…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2017-07-13 · tag F0371 — pattern
    Store, cook, and serve food in a safe and clean way.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview of staff, it was determined that facility staff failed to maintain equipment and prepare foods in a manner that ensures a safe and sanitary food service. The findings include: On initial tour on July 10, 2017 at 9:45 AM, the drain for the ice machine was directly connected to the waste floor drain. This was verified by interview of the Dietary Manager. An air gap is required between food contact equipment and the sewage disposal system to prevent contamination in case of sewage backup. On July 12, 2017, at 1:15 PM, the walk in freezer thermometers (two) read 22- 24 degrees Fahrenheit (F). The individual ice cream cups were soft, revealing that they were partly melted. The Dietary Manager voluntarily discarded the ice cream cups. In the walk in refrigerator, a large cooked piece of leftover roast beef was observed with a cook date of July 10, 2017. The Dietary Manager stated that she did not have forms to record cooling temperatures and had not monitored the cooling of the meat. Interview of the cook indicated that he used ice baths to cool cooked…

    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 · D2017-07-13 · tag F0500 — isolated
    Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and medical records review, it was determined that facility staff failed to follow doctor's orders and arrange a psychiatric evaluation of a resident who qualified for a professional evaluation from psychiatric services. The findings include: On July 13, 2017 at 10:45 A.M. a review of Resident #92's medical records was conducted. It was revealed that the doctor's order for a psychiatric evaluation and follow ups was never ordered by the facility. The Order was written on April 25, 2017 as Please consult psychiatric for eval and follow ups. A phone interview with the Medical Director revealed that the order was never followed through by the facility. The Unit Manager of the South Wing was made aware. Failure to follow doctor's orders for professional resource lead to a delay in an ordered medical evaluation for the resident.

    Administration Deficiencies · Deficient, Provider has date of correction
  • No harm found · B2018-11-01 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and interviews of facility staff, it was determined the facility failed to ensure that garbage and refuse was disposed of properly. The findings include: On October 31, 2018, surveyors toured the outside dumpster area. The following observations were made: 1) All dumpster's were left open when not in use. One dumpster was missing the side door preventing it from being closed. Dumpster's must remain closed to prevent harborage of pests. 2) The Biohazard waste container lid was bent upwards and not completely closed.

    Nutrition and Dietary 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.

“Disputed” is CMS’s own flag, not our reading: the CMS deficiency file records whether the home has formally contested a citation, and we reproduce that. IDR is Informal Dispute Resolution, run by the state survey agency that wrote the citation; IIDR is Independent Informal Dispute Resolution, a separate process before an outside entity, available when CMS has proposed a civil money penalty. They are different processes and we mark them differently. Two things to hold at once. A disputed citation is still a citation — it was written by a surveyor, it stands on the record unless and until it is changed, and we neither hide it nor discount it. And we cannot tell you how the dispute came out: CMS publishes that a citation is under dispute, not the outcome, so a tag marked here may since have been upheld, reduced, or deleted, and an unmarked tag may have been disputed and resolved before this file was cut. Ask the home what it disputed and why — it is entitled to tell you, and the answer is often the most informative thing on this page.

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

$127,440 in federal fines across 1 penalty.

  • $127,440 — penalty dated 2026-04-14

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to GENESIS HEALTHCARE — 184 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 52.4+2.6 vs chain
Health inspection 4 of 52.3+1.7 vs chain
Staffing 3 of 52.5+0.5 vs chain
Quality measures 5 of 53.5+1.5 vs chain
The other 183 homes this chain runs (chain average 2.4★, per CMS)
1 of 5Alexandria Care CenterLos Angeles, CA 1 of 5Bay Crest Care CenterTorrance, CA 1 of 5Bethlehem North Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bethlehem South Skilled Nursing And RehabilitationBethlehem, PA 1 of 5Bridgeville Rehabilitation & Care CenterBridgeville, PA 1 of 5Brightwood CenterFollansbee, WV 1 of 5Carlisle Skilled Nursing And Rehabilitation CenterCarlisle, PA 1 of 5Casa De Oro CenterLas Cruces, NM 1 of 5Devonshire Care CenterHemet, CA 1 of 5Gettysburg CenterGettysburg, PA 1 of 5Glenwood CenterFlorence, AL 1 of 5Heritage CenterHuntington, WV 1 of 5Hidden Valley CenterOak Hill, WV 1 of 5Inners Creek Skilled Nursing And Rehabilitation CeDallastown, PA 1 of 5Jersey Shore Skilled Nursing And Rehabilitation CeJersey Shore, PA 1 of 5Kingston Court Skilled Nursing And RehabilitationYork, PA 1 of 5Las Palomas CenterAlbuquerque, NM 1 of 5Lebanon Center, Genesis HealthCareLebanon, NH 1 of 5Lebanon Skilled Nursing And Rehabilitation CenterLebanon, PA 1 of 5Linden Grove Health Care CenterPuyallup, WA 1 of 5Magnolia RidgeGardendale, AL 1 of 5Marmet CenterMarmet, WV 1 of 5Meridian CenterHigh Point, NC 1 of 5Merry Wood LodgeElmore, AL 1 of 5Mount Olive CenterMount Olive, NC 1 of 5Mountain Ridge Center, Genesis HealthCareFranklin, NH 1 of 5Oak Grove CenterWaterville, ME 1 of 5Oceanside Skilled Nursing And RehabilitationHampton, NH 1 of 5Orchard Park Health Care & Rehab CenterTacoma, WA 1 of 5Parkersburg CenterParkersburg, WV 1 of 5Pembroke CenterPembroke, NC 1 of 5Pine LodgeBeckley, WV 1 of 5Playa Del Rey CenterPlaya del Rey, CA 1 of 5Pocahontas CenterMarlinton, WV 1 of 5Pottstown Skilled Nursing and Rehabilitation CentePottstown, PA 1 of 5Putnam CenterHurricane, WV 1 of 5Ridgewood CenterRidgewood, NJ 1 of 5Rio Rancho CenterRio Rancho, NM 1 of 5River City CenterDecatur, AL 1 of 5River Ridge CenterKennebunk, ME

Showing 40 of 183; lowest-rated first.

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

Who owns this facility

Owner / managerTypeRoleShareSince
FC-GEN OPERATIONS INVESTMENT LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2012
GEN OPERATIONS I LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2012
GEN OPERATIONS II LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2012
GENESIS HEALTHCARE INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
GENESIS HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2012
GENESIS HOLDINGS LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
SUN HEALTHCARE GROUP INCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 02/02/2015
SUNBRIDGE HEALTHCARE LLCOrganization5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 04/20/2007
WHITMAN, ARNOLDIndividual5% OR GREATER INDIRECT OWNERSHIP INTERESTNO PERCENTAGE PROVIDEDsince 12/01/2012
BERG, MICHAELIndividualCORPORATE OFFICERsince 12/01/2012
BRIDGEFORD, LAURAIndividualCORPORATE OFFICERsince 06/01/2024
MENDELSON, AVIIndividualCORPORATE OFFICERsince 06/01/2024
MORRIS, DIANEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 12/27/2023
RADCLIFFE, STACEYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2025
TAVAKOLI-JALILI, NADERIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2024
KHI LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 04/20/2007
MARYLAND HARBORSIDE LLCOrganizationGENERAL PARTNERSHIP INTERESTsince 02/02/2015
HARBORSIDE HEALTHCARE ADVISORS LIMITED PARTNERSHIPOrganizationLIMITED PARTNERSHIP INTERESTsince 04/20/2007
HARBORSIDE HEALTHCARE LIMITED PARTNERSHIPOrganizationLIMITED PARTNERSHIP INTERESTsince 04/20/2007
HARBORSIDE HEALTHCARE LLCOrganizationLIMITED PARTNERSHIP INTERESTsince 04/20/2007

CMS files one row per role, so the 23 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

13 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.

−$3K
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses

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.

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 215264. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2022-06-14, 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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