Charlotte Hall Veterans Home

Location & what’s nearby

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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

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.

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.

27.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that worse than the national rate. This is CMS’s risk-adjusted rate over 27 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 34.2% 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 73 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.

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.

Staffing

How full it usually is: this home is certified for 286 beds and averages 210.0 residents a day — about 73% occupied, or roughly 76 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 4.41 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.70 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.74 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.77 hrs/resident/day on weekends vs 4.67 on weekdays — 19% thinner on weekends. RN hours go from 0.84 to 0.34 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%. 1 administrator has left in the past year.

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

Inspection trend

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

Inspection deficiencies

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

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

33 citations, most serious first. The 15 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · Jcited before2022-08-15 · 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 observations, staff interviews, and review of medical record documentation, it was determined that the facility failed to: 1) maintain a safe and effective system for securing medication, treatment supplies, and hazardous medical equipment in their designated carts on nursing units with confused and wandering residents. This practice was noted over three days (7/25/2022-7/27/2022) and included six instances where medication/treatment carts were observed unlocked and unattended. Unsecured carts were noted on 3 of the 6 nursing units. Additionally, the facility failed to: 2) ensure that a resident was assessed for being able to self administer medication. This was evident for 1 (Resident #78) of 1 resident reviewed for medication self administration. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy and the facility was provided verbal and written notification of this determination at 1:10 PM on 07/27/2022. The date of…

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

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2018-12-04 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview of facility staff it was determined the facility staff failed to keep Resident #175 safe from injury by failing to intervene and ensure that Resident #175 was supervised when smoking and when Resident #175 showed a decline in cognitive status in activities of daily living. This was evident for 1 out of 7 residents reviewed for hospitalization and 1 out of 12 residents reviewed for accidents. It was determined that the facility's failure to ensure that Resident #175 was safe to smoke without supervision resulted in past non-compliance immediate jeopardy which existed from 7/5/18 through 10/20/18. The Nursing Home Administrator was notified on 11/30/18 at 4:30 P.M. The findings include: Resident #175's medical record was reviewed on 11/30/18. Medical record review revealed that Resident #175 has resided at the facility since February 2018. The resident has diagnoses that include nicotine dependence and a history of a cerebral vascular accident resulting in left sided…

  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 · Past Non-Compliance
• Actual harm · G2025-04-04 · 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 record review and interviews during a complaint survey, the facility failed to ensure each resident was provided care and treatment in accordance with professional standards of practice for one resident (Resident #9) of 40 sampled residents. Specifically, the facility failed to ensure Resident #9, a resident at risk for dehydration, was monitored for heat related illness and provided with sufficient hydration when temperatures in the building rose above 81 degrees from 4/30/24 until 5/2/24. On the morning of 5/2/24, Resident #9 was found nonresponsive with an elevated temperature and was sent to the hospital where they were treated for heat exhaustion and dehydration. Resident #9 experienced a significant change in condition following this event. This failure resulted in actual harm for Resident #9 that did not rise to the level of immediate jeopardy. Cross reference to F584: safe, clean, comfortable, homelike environment The findings include: According to the Centers for Disease Control and Prevention…

  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
• Actual harm · G2022-08-15 · 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

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, resident record review, and staff and resident interviews, it was determined that the facility failed to: 1) ensure that residents were free from abuse (Resident #17); 2) ensure that residents were free from neglect (Resident #10); 3) maintain adequate supervision of residents with documented histories of aggressive behavior with care planned interventions in place including to perform routine checks to prevent potential 'inappropriate,' and 'aggressive' behavior (Resident #187); and 4) prevent abuse occuring from an employee towards a resident (Resident #235). This was found to be evident for 4 out of 49 residents reviewed for abuse and neglect. As a result of this failure, actual harm was identified for Resident #17. The findings include: 1) A review of the nurse's notes for Resident #17 was conducted on 08/09/2022 at 9:00 AM. The nurses note stated on 05/27/2022 at approximately 4:20 PM the Unit Manager # 42 was told by Resident #17 and his/her roommate Resident # 148 that Geriatric…

  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
• Actual harm · H2018-12-04 · 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 medical record review and interview of facility staff it was determined the facility staff failed to ensure that care plan interventions were implemented: 1) the facility failed to intervene and revise Resident #175's care plan related to tobacco use. This failure occurred when Resident #175 showed signs of decline in cognitive status and activities of daily living, indicating that the resident was not safe to smoke without supervision. It was determined that the facility's failure to revise Resident #175's care plan interventions resulted in an actual harm to the resident from a smoking related accident with injury, and 2) the facility failed to revise and update the care plan that addressed Resident #51's care after a change in condition. This was evident for 2 out of 12 residents reviewed during the survey process. The findings include: 1) Resident #175's medical record was reviewed on 11/30/18. Medical record review revealed that Resident #175 has resided at the facility since February 2018. The…

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

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2025-07-25 · tag F0558 — failed to accommodate residents' needs and preferences — pattern
  Reasonably accommodate the needs and preferences of each resident.
  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 ensure residents had their call bell within reach to notify the staff when assistance was needed, This deficient practice was evidenced in 5 (#80, #90, #125, #190, #191, #201) residents observed without their call bells during the initial observation rounds during the recertification survey.The findings include:During the surveyor's initial observation rounds on 07/16/25 at 9:49 am the surveyor observed Resident #80 call bell behind the bed. Geriatric Nursing Assistant (GNA) # 10 confirmed the surveyor's findings. At 10:08 am the surveyor observed Resident #191 call bell hanging off the left side of the bed close to the floor, which was not in reach of the resident. At 10:09 am the surveyor observed Resident #125 call bell hanging on the right side of the bed. GNA #12 confirmed the surveyor's findings. At 10:12 am Resident #90 was sitting in their wheelchair on the L side of the bed and the call bell was on the right side of the bed on the wall. 10:52 am Resident #201 call bell was hanging from…

  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 · E2025-07-25 · 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 of the facility's kitchen and food services, it was determined that the facility failed to maintain food service equipment in a manner that ensures safe and sanitary food service operations. This was identified during multiple observations of kitchen food service operations. The findings include: On 7/17/25 at 10:33 AM a tour of the kitchen was conducted which revealed:- A pair of eyeglasses placed on top of dishwasher- One 30-ounce personal drinking container on top of the dishwasher- An empty hand paper towel dispenser, one empty soap dispenser located at the hand wash sink in dish washer area- An empty paper towel dispenser located next to the hand sink near the walk-in fridge of the food prep area of the kitchen. On 7/15/25 at 11:35 AM a continued tour of the walk-in refrigerator revealed:- one long silver tray containing three large blue bags of raw chicken without a label noting its thaw date. On 7/15/25 at 11:45 AM Refrigerator #4's internal temperature taken from the hanging thermometer read 50 degrees Fahrenheit; the temperature viewed again ten…

  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 · Dcited before2025-07-25 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation and interview it was determined that the facility staff failed to ensure a dignified existence was maintained as evidenced of a resident's fitted sheet being heavily soiled and the mattress was half covered. This deficient practice was evidenced in 1 (#123) resident observed with a compromised dignified existence during the recertification survey.The findings include:On 07/16/25 at 10:28 am the surveyor observed Resident #123 fitted sheet with large spots of a green substance and half of the mattress was exposed. LPN #14 was in the room giving medications to the resident's roommate. Afterwards, LPN #14 walked past Resident #123 and left the room without offering the resident any assistance. The surveyor checked the resident electronic health record to see if there was documentation to verify assistance was offered to the resident and refused. On 07/23/25 at 11:39 am during an interview with LPN Unit Manager #20 he/she verbalized the resident tries to be independent as possible and is resistant to care and that should be care planned. The staff allows him to meet…

  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 · D2025-07-25 · tag F0605 — failed to not use drugs as a restraint — isolated
  Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interview it was determined that the facility staff failed to attempt to decrease a resident's psychotropic medication when they had no documented behaviors for at least five months. This deficient practice was evidenced in 1(#80) of 1 resident records reviewed for gradual dose reductions of psychotropic medications during the recertification survey.The findings include:On 07/22/25 at 9:03 am the surveyor reviewed Resident #80 Psychiatric notes dated 12/19/24, 03/20/25, and 06/19/25. The note dated 12/19/24 indicated the resident had a failed gradual does reduction (GDR) attempt in 11/24. According to Psychiatric Nurse Practitioner (NP) #21 note the resident displayed agitation, the use of profane language, and the inability to adhere to safety precautions when the psychotropic medication was decreased. The notes dated 03/20 and 06/19 indicated a GDR was not indicated. A review of the resident's behavioral monitoring documentation dated 03/01/25 - 07/21/25 the staff documented the resident did not observe any behavioral problems from the Resident #80…

  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 before2025-07-25 · 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 record review and interview it was determined that the facility staff failed to initiate a dental care plan for a resident who had dental concerns. This deficient practice was evidenced in 1 (#74) of 1 resident reviewed for dental concerns during the recertification survey.The findings include:On 07/17/2025 at 9:30 am while speaking with Resident #74 responsible party/emergency contact they verbalized the resident had a lot of issues with his/her bottom teeth and they were supposed to get the resident back to the dentist. On 07/21/25 at 10:15 am a review of Resident #74 electronic health record (EHR) revealed the resident did not have a dental care plan although the facility staff was aware the resident had dental concerns. The surveyor received a copy of an appointment request dated 07/07/25 for the resident related to dental pain. On 07/21/2025 at 3:03 pm during an interview with the Director of Nursing (DON) the surveyor reported the resident did not have a dental care plan. The DON verbalized the Unit Managers should make sure the care plans are completed. MDS helps but…

  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 · D2025-07-25 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, and interviews it was determined that the facility staff failed to provide a resident with a shower for several months and failed to consistently provide a resident with a shower. This deficient practice was evidenced in 2 (#4 & #80) resident records reviewed for ADL care during the recertification survey.The findings include:During observation rounds on 07/17/25 at 10:57 AM the surveyor asked Resident #4 when the last time he/she had a shower. The resident verbalized he/she has not had a shower in several months. There was a strong odor of urine in the resident's room.On 07/21/25 at 10:45 AM a review of the Shower Schedule for the residents on 2B revealed Resident #80 was scheduled to have a shower on Monday and Thursday. The facility's documentation revealed the resident had not received a shower twice a week. There was no documentation to verify the resident received a shower on 07/17, 7/03, 06/26, 6/12, 06/05, and 06/02. There was no documentation to indicate the resident refused a shower. The surveyor went to Resident #4 room on 07/23/2025…

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

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2025-07-25 · tag F0761 — failed to label and store drugs safely — isolated
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations and staff interview it was determined that the facility staff failed to: 1.) ensure proper temperature storage of medications to preserve medication integrity and 2.) properly label multi-dose medications with the complete date that the medication was opened. This was true for 2 of 7 medication carts reviewed during the annual survey. The findings include: 1. On 7/22/2025 at 10:52 AM, a medication storage observation was conducted on the first floor accompanied by Nurse #23. Observation of the medication cart for the High Hall revealed 2 unopened insulin pens that were clearly marked to refrigerate until opened in the medication cart. The surveyor verified that the insulin pens were supposed to be refrigerated until open with employee #23. Nurse #23 acknowledged surveyors' findings discarded the insulin pens. 2. On 7/22/25 at 1:58 PM, the surveyors observed an illegible handwritten open date on a multidose solution bottle located inside the medication cart. An interview with LPN #8 indicated that she could not decipher the date on the bottle as it had been worn…

  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 · D2025-07-25 · 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, infection control policy review, and interview with staff, it was determined that the facility: 1) failed to ensure that multi-use equipment was properly sanitized after each use and 2) failed to provide accurate transmission based precautions signage outside resident rooms. This was evident for 1 of 4 medication carts and 2 out of 5 residents' doors observed during the annual survey. It was also observed that the facility staff failed to maintain infection control practices for a resident who had a urinary drainage bag as evidenced by the drainage port being on the floor with the tubing being heavily soiled, and a resident's oxygen tubing was on the floor. This deficient practice was evidenced in 2 (#107, #209)) of 5 residents observed with a drainage bag or oxygen therapy during the recertification survey. The findings include: On 7/22/25 at 2:25 PM, an interview with Licensed Practical Nurse (LPN # 9) disclosed that the Freestyle Libre 2 was cleaned after use with 70% isopropyl alcohol wipes after each use. At 3:00 PM, an observation was made of a contact…

  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 · E2025-04-04 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review and interviews during a complaint survey, the facility failed to ensure the resident environment was safe and comfortable for two of four occupied care wings. Specifically, the facility failed to maintain safe, comfortable temperatures on the A and B wings of the facility during planned maintenance of the cooling system; temperatures on these wings were consistently above 81 degrees Fahrenheit for approximately 48 hours. Cross reference to F684: Quality of care The findings include: The Procedure titled Code Purple: Severe Hot Weather with Loss of Cooling, last revised 2/1/15, documented the procedure should be followed to prevent abnormally high body temperature if there was a loss of cooling function during hot weather when the facility's temperatures reach 81 degrees Fahrenheit and remained so for 4 hours. Action steps to be taken in the event of a Code Purple included the following: to keep informed of weather bulletins, have a portable NOAA weather radio available, move patients/residents to another air-conditioned part of the facility if available,…

  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 · D2025-04-04 · 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 observations, interviews, and record review, the facility failed to immediately notify the Resident court appointed Guardian (G32) when Resident (R17) experienced a significant change and deterioration of a life-threatening condition for one of 40 sampled residents. The facility census was 204. The Findings Include: Review of R17's Face Sheet documented R17 was admitted on [DATE]. The face sheet showed G32 was a medical court appointed guardian. Review of R17's care plan dated [DATE] directed staff to notify G32 of any changes to R17's health status. Record Review of the annual Minimum Data Set assessment (MDS), dated [DATE], revealed R17 had a BIMS score of 00/15 (indicating severe mental impairment). R17 was dependent on staff regarding activities of daily living (ADLs). Record review of R17's SBAR form dated [DATE] at 06:04 AM, Licensed Practical Nurse (LPN)33 documented R17 had an elevated respiration. R17 was not able to respond to tactile stimuli. MD made aware and gave an order given to send, R17…

  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

“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.

Fines & penalties

$66,671 in federal fines across 1 penalty.

• $66,671 — penalty dated 2025-04-04

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.

Who owns this facility

CMS files one row per role, so the 11 rows in the source record cover these 6 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

This home reported $3.6M paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

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

Cost & finances

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

What families pay in MD