Willow Brooke Ct Skilled Care Ctr At Heron Point
501 Campus Avenue, Chestertown, MD 21620 · Non profit - Corporation · 38 certified beds · (410) 778-7300 Medicare & Medicaid certified
This home’s record is mixed — some reassuring signs, some worth asking about.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- 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 recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
- a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $15,440 in federal fines (most recent 2024-02-23)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | Not rated |
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
| Overall quality measures | Not rated |
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 improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
58.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 37 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 5.93 therapist hours per resident per day in 2026Q1 — more than 100% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 58.8%CMS range 47.0–74.5 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.2%CMS range 8.1–19.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.87 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 38 beds and averages 1.9 residents a day — about 5% occupied, or roughly 36 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 4.75 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.76 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.22 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 4.12 hrs/resident/day on weekends vs 5.00 on weekdays — 18% thinner on weekends. RN hours go from 1.99 to 1.20 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
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 11 most serious are shown; the remaining 15 are one tap away and print in full.
- Immediate jeopardy · Jcited before2024-02-23 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews it was determined that the facility failed to ensure a safe environment for a resident diagnosed with a major depressive disorder. This was found to be evident for 1 (Resident #178) out of 1 resident reviewed for accidents. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy Past Non-compliance. The findings include: According to the National Institute of Health depression (also known as major depression, major depressive disorder, or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working. During a review of a Facility Reported Incident (FRI) investigation conducted on 02/16/2024 at 8:44 AM, it was revealed that Resident #178, with a diagnosis of a major depressive disorder, was found with a knife attempting to cut his/her wrist. On 02/16/2024 at 9:00 AM a 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.
- Potential for harm · F2025-12-11 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This was found to be evident during the observation of the kitchen during the recertification survey. This practice had the potential to affect all residents consuming food and beverage prepared and provided by the facility's kitchen. The findings include: During the initial tour of the main kitchen conducted on 12/08/2025 at 8:02 AM the Surveyors and Certified Dietary Manager (CDM) observed the following expired food items in the walk-in refrigerator: Black beans opened 12/03/25 expired 12/07/25, Maraschino Cherries opened 12/03/25 expired 12/06/25, Walnut topping opened 11/29/25 expired 12/06/25, Cream of Crab soup opened 12/04/25 expired 12/07/25, Corn beef opened 12/03/25 expired 12/06/25, Kalamata Olive Oil 12/03/25 - 12/06/25, 2 Cheese balls and 1 Cheese log opened 12/07/25 with no expiration date, Dannon…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-23 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interviews, it was determined that the facility failed to put a system in place to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 4 out of 5 GNAs (GNA #6, #7, #8, #9, & #10) reviewed for competencies skill evaluations. The findings include: On 02/14/2024 at 8:10 AM, the surveyor reviewed the employee files and was unable to locate skill competency evaluations for Geriatric Nursing Assistants (GNA) #6, #7 #8, #9 & #10. During an interview conducted on 02/14/2024 at 11:01AM, GNA #7 stated she participated in the Olympic skills competency assessment which required return demonstrations in September of 2023. During an interview conducted on 02/14/2024 at 2:00 PM, the surveyor advised the administrator that employee files did not include the competency skills evaluation. The Administrator stated she would investigate it to see if the evaluations were stored somewhere else. On 02/14/2024 at approximately 2:45 PM, the Administrator advised the surveyor that only GNA #7 attended the Olympic skill…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0625 — isolatedNotify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview with staff, it was determined that the facility failed to have an effective system in place to ensure that residents and resident representatives are notified in writing of the bed hold policy at the time of discharge/transfer to the hospital. This was found to be evident for 2 (Resident #14 and Resident #183) of 3 residents reviewed for hospitalizations during the investigative portion of the annual survey. The findings include: A Bed Hold is the act of holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization. It must be provided to all facility residents regardless of payment source. Bed Hold policy should be disclosed in the admission packet during initial admission to the facility and it should be disclosed to resident and, if applicable, resident representatives at the time of transfer; if emergency transfer, within 24 hours. On 2/16/2024 at 9:00 AM, a review of Resident #14's electronic medical records revealed that the resident had been transferred to the hospital on 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-02-23 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to limit the timeframe for a PRN (as needed) psychotropic medications to 14 days. This was evident for 1 resident (Resident #11) out of 5 residents investigated for medication regimen review during the annual survey. The findings include: Psychotropic drug is defined as any drug that affects brain activities associated with mental processes and behavior. Psychotropic drugs include, but are not limited to the following categories: anti-psychotics, anti-depressants, anti-anxiety, and hypnotics. On 2/22/2024 at 1:00 PM during a review of Resident #11's electronic medical record, the Surveyor discovered that the resident was admitted to the facility on [DATE] with diagnoses of but not limited to anxiety disorder, major depressive disorder, neurocognitive disorder with lewy bodies, and cognitive impairment. Resident #11 had a psychiatric assessment on 6/29/2022 with a recommendation to add a psychotropic drug, Ativan every 12…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record reviews and interviews it was determined that the facility failed to ensure the medication error rate was 5% or less. This was found to be evident for the medication administration observation during the annual survey. The findings include: MiraLAX is a laxative powder made for providing gentle constipation relief. On Thursday 02/15/2024 at 7:36 AM, the surveyor observed Registered Nurse (RN) #11 administer medications for Resident #21. The RN mixed 17 GM (grams) of MiraLax Oral powder in an unknown amount of water. The RN poured the packet of 17 gms of MiraLAX powder into a white plastic cup and filled the cup to the top rim with water. During an interview conducted on 02/15/2024 at 7:35 AM, the surveyor asked the RN how many fluid ounces were poured into the cup, the RN stated she was unsure. A review of Resident #11's Medication Administration Record (MAR) revealed an order that stated MiraLax Oral Packet 17 GM (Polyethylene Glycol 3350). Give 1 packet by mouth one time a day every Mon, Wed, Fri for Constipation administer in 6- 8oz of water. This…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0761 — failed to label and store drugs safely — isolatedEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations, record reviews and interviews it was determined that the facility failed to ensure medication was stored properly. This was found to be evident for 1 out of 2 medication carts observed during the annual survey. The findings include: Prosource provides nutrients necessary for the dietary management of protein-energy for protein malnutrition and protein deficiency. On 02/15/2024 at 8:02 AM the surveyor observed an opened bottle of Resident #16's Prosource stored in the bottom drawer of RN #11's medication cart. The Prosource bottle was opened and undated. During an interview conducted on 02/15/2024 at 8:06 AM, RN #11 stated she would discuss with the Director of Nursing on how to handle the opened and undated bottle of Prosource for Resident #16. During an interview conducted on 02/15/2024 at 11:17 AM the surveyor advised the Administrator of the observed medication storage finding.
- Potential for harm · E2024-02-23 · tag F0609 — failed to report abuse allegations — patternTimely 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the facility's documentation review and staff interview, it was determined the facility failed to report allegations of abuse and injury of an unknown source to the local enforcement agency. This was found to be evident for 4 (residents # 7, #13, #181, & #11) out of 5 residents reviewed for abuse. The findings include: A review of the facility reported incident investigations conducted on 02/15/2024 at 11:29 AM revealed Resident #181 reported to the facility that Geriatric Nursing Assistant (GNA) #27 would not let the resident pass by, the resident pushed the GNA and the GNA pushed the resident and the resident fell back onto the floor. Further review of facility reported incident investigation revealed the facility failed to report the allegation of abuse to the local law enforcement agency. A review of the facility reported incident investigations conducted on 2/22/2024 at 9:25 AM revealed Geriatric Nursing Assistant (GNA) #10 called Licensed Practical (LPN) #25 into resident's room [ROOM NUMBER]…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2024-02-23 · tag F0610 — failed to investigate and act on abuse reports — patternRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of Facility Reported Incidents (FRI) and interview with staff, it was determined that the facility failed to complete a thorough investigation. This was evident for 6 (Resident #3, #4, #5, #21, #7, and #13) out of 13 residents investigated for Facility Reported Incidents. The findings include: Geri sleeves protect the arms and legs from skin tears, abrasions, and light bruising caused by friction and shearing in the bed and wheelchair. On 2/20/2024 at 1:30 PM, the Surveyor reviewed Resident #3's electronic and paper medical record which revealed that on 5/9/2023 at 7:37 PM, Geriatric Nursing Assistant (GNA) #28 reported to a nurse that when she got the resident up from the bed to the chair, she noticed a patch of blood on the resident's upper left sleeve. Resident #3 stated that he/she did not know how it happened. During further review, the Surveyor located a progress note written by Licensed Practical Nurse (LPN) Staff # 26 on 5/9/2023 at 7:41 PM. The note stated that a GNA [#28] notified this nurse about resident had a skin tear to [resident #3] left upper arm,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on clinical record review, observation, and staff interview it was determined that the facility staff failed to ensure residents' care plans were followed. This was evident for 1 (#16) out of 29 residents who were part of the survey sample. The findings include: A review of Resident #16's clinical record on 2/15/24 and 2/16/24 revealed that the interdisciplinary team (IDT) developed a care plan on 5/14/21 to address the identified concern that the resident is a risk for wandering. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. One of the interventions the IDT developed and planned to implement was: My Wander Alert device will be checked for function, placement and expiration regularly. A review of the resident's Treatment Administration Records (TAR) for the months of May, June, and July of 2021 revealed that the facility did not check for function, placement, and expiration until 7/8/21 at 7:32 PM when a nurse wrote a note: Wander guard location left walker,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-02-23 · tag F0740 — failed to provide behavioral / mental-health care — isolatedEnsure each resident must receive and the facility must provide necessary behavioral health care and services.
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 reviews and interviews it was determined that the facility failed to ensure a resident with major depressive disorder receive proper care and treatment. This was found to be evident for 1 (resident #178) out of 1 resident reviewed for behavioral health. The findings include: According to the National Institute of Health depression (also known as major depression, major depressive disorder, or clinical depression) is a common but serious mood disorder. It causes severe symptoms that affect how a person feels, thinks, and handles daily activities, such as sleeping, eating, or working. On 02/16/2024 at 8:40 AM a review of Resident #178's medical record revealed the resident had the following diagnoses: major depressive disorder and anxiety disorder due to known physiological condition. Further review of the resident's medical record revealed a hospital discharge summary that stated the resident was brought to the hospital on [DATE] for worsened behavioral changes. The behavioral changes consisted 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.
Show the remaining 15 citations
- Potential for harm · E2019-04-09 · tag F0636 — patternAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation, and staff interview, it was determined the facility staff failed to complete the required annual MDS assessments, admission assessment and 5 day assessments within the required timeframes. This was evident for 4 of 25 residents reviewed for MDS completion. Findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and Hearing patterns, Vision patterns, Physical functioning, and Structural problems which includes the assessment of Range of motion, Continence, Psychosocial well-being, Mood and Behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use, and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-04-09 · tag F0638 — patternAssure that each resident’s assessment is updated at least once every 3 months.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation and staff interview, it was determined the facility staff failed to complete the required quarterly MDS assessments within the required timeframes. This was evident for 14 of 25 residents reviewed for MDS complettion. Findings include: The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team develops the plan of care for the 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.
- Potential for harm · E2019-04-09 · tag F0645 — patternPASARR screening for Mental disorders or Intellectual Disabilities
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, it was determined the facility staff failed to assess Resident (#19) for PASRR. This was evident for 1 out of 1 resident selected for review of the PASRR process and 31 out of 31 residents selected for review during the annual survey process. The findings include: The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The Minimum Data Set (MDS) 3.0 is a core set of screening, clinical, and functional status elements that support a comprehensive assessment for all residents. The Level I PASRR screen must be completed by either the nursing facility or the referring doctor for every individual who will be admitted to a nursing facility. A preliminary screen is to identify individuals who may have Mental Illness (MI), Intellectual Disability (ID), and/or Related Condition (RC). The nursing facility is responsible for ensuring a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-04-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — patternEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation and interview, it was determined the facility staff failed to provide Residents (#4, #11 and #17)an environment free from potential accidents. This was evident for 3 of 3 residents selected for review of accidents during the survey process and 3 of 25 residents selected for review during the annual survey process. The findings include: 1. The facility staff failed to provide fall interventions for Resident #11 to decrease the number of falls. Medical record review for Resident #11 revealed the following documentation related to falls for the resident: 4/3/19: fall- on floor with feet in front of her/him- slid out of bed, 2/15/19-on floor on butt with back against wall-legs in front of her/him, 2/13/19-sitting on floor in room in front of bed--back against her bed and legs and feet were in front of her/him-appears to have slid out of bed, 1/17/19 at 620 AM- resident heard yelling- entered the room to find resident sitting on bottom with her/his back against the bed, 12/27- resident noted with 2 falls in 3 days-was found on floor 5:30 AM,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-04-09 · tag F0745 — failed to provide medically-related social services — patternProvide medically-related social services to help each resident achieve the highest possible quality of life.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation and interview, it was determined the facility staff failed to complete Preadmission Screening and Resident Review (PASARR) for residents. The facility failed to complete certifications of incapacity to make medical decisions for resident before having healthcare agents make medical decisons. This was evident for 25 of 25 residents reviewed for PASARR's and 2 of 2 residents (#26 and #12) reviewed for dementia during the annual survey process. The findings include: 1. On 4-9-19 at 11:50 AM the Nursing Home Administrator and Director of Nursing confirmed that certifications of incapacity by two physicians have not been completed on the facilities residents including #26 and #12 before medical decisions are made by the surrogate decision maker. 2. The facility staff social worker failed to conduct a PASRR screening for Resident #19. The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status which forms the foundation of the comprehensive assessment for all residents of long-term care…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-04-09 · tag F0758 — failed to limit and justify psychotropic drugs — patternImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, it was determined the facility staff failed to conduct an AIMS assessment for Resident (#12 and #16) in a timely manner. This was evident for 2 of 5 residents selected for unnecessary medication review and 2 of 25 residents selected for review during the annual survey process. The findings include: Some people may develop muscle related side effects while taking anti-psychotic medications such Seroquel and Risperidone. The technical terms for these are extrapyramidal effects (EPS) and tardive dyskinesia (TD). Symptoms of EPS include restlessness, tremor, and stiffness. TD symptoms include slow or jerky movements that one cannot control, often starting in the mouth with tongue rolling or chewing movements. Persons taking any kind of antipsychotic medication need to be monitored for movement disorders. The AIMS (Abnormal Involuntary Movement Scale) aids in the early detection of tardive dyskinesia as well as providing a method for on-going surveillance. The Abnormal Involuntary Movement Scale (AIMS) is a rating scale that was designed in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-09 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's 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, observation and interview, it was determined the facility staff failed honor a resident's (#26) designation of a health care representative as named in their Advanced Directive. This was evident for 1 of 1 resident selected for review of choices during the annual survey process. The findings include: When admitted to the facility on [DATE] Resident #26 provided a copy of his/her Advanced Directive from 2007 which included Part A-Appointment of Health Care Agent. Resident #26 named his/her spouse to act as health care agent and if spouse not able or willing then a sibling was named. Resident #26 has dementia and is unable to make healthcare decisions. Social Worker (SW) #5 had allowed the paid caregiver to sign on 2-27-19 Resident #26's Notice of Medicare Non-Coverage. On 3-8-19 the spouse provided the facility with a paper he/she wrote designating their paid care to make any and all decisions on behalf of the care of Resident #26 in spouse's absence. The spouse's paid caregiver…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-09 · tag F0561 — failed to honor residents' choices — isolatedHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review and interview, it was determined the facility staff failed to promote Resident (#6's) self-determination. This was evident for 1 of 25 residents selected for review of self-determination during the survey process. The findings include: Medical record review for Resident #6 revealed on 1/24/19 the physician ordered: discontinue weights, comfort care. Further record review revealed the facility staff weighed the resident on 4/1/19. Interview with the Director of Nursing on 4/8/19 at 12:00 PM revealed the Geriatric Nursing Assistant took the resident's weight by accident. Interview with the Director of Nursing on 4/9/19 at 1:30 PM confirmed the facility staff failed to promote self-determination for Resident #6 by obtaining a weight when there was a no weight order.
- Potential for harm · D2019-04-09 · tag F0580 — failed to tell family and doctor about changes — isolatedImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, it was determined the facility staff failed to notify Resident (#5's) responsible party of a change in medication and failed to notify the CRNP/physician when holding medications for Resident (#27). This was evident for 1 of 25 residents selected for review of notification of change during the annual survey process. The findings include: 1. The facility staff failed to notify the responsible party for Resident #5 of a change in medication. Medical record review for Resident #5 revealed on 3/18/19 the resident complained of not feeling well. The resident was offered ginger ale and refused. At 12:30 PM, the facility staff notified the Certified Registered Nurse Practitioner (CRNP). The CRNP ordered the resident Zofran 8 milligrams by mouth every 8 hours as needed for nausea or vomiting and ordered Loperamide 2 milligrams by mouth as needed for loose stools; however, there is no evidence of Resident #5's responsible party being notified of the new medication orders. Interview with the Director of Nursing on 4/9/19 at 1:30 PM confirmed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-09 · tag F0623 — isolatedProvide 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 — the official record, unedited, may be distressing
Based on medical record review and interview, it was determined that the facility failed to notify the responsible party in writing of a Resident's (#26) transfer to the hospital. This was evident for 1 of 1 residents reviewed for hospitalizations. The findings include: On 1-14-19 Resident #26 fell and sustained an injury to the left leg and was transferred to the hospital for further care. The facility verbally notified the emergency contact but did not send a written notification of the hospital transfer and the reason for the transfer. This finding was confirmed with the Nursing Home Administrator and the Director of Nursing on 4-5-19 at 9:30 AM.
- Potential for harm · D2019-04-09 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, it was determined the facility staff failed to provide an environment to promote the highest well-being for Residents (#11, #12 and #27). This was evident for 3 of 25 residents selected for review of well-being during the annual survey process. The findings include: 1. The facility staff failed to notify the Certified Registered Nurse Practitioner (CRNP) of a urinalysis result in a timely manner. Medical record review revealed on 1/3/19 the physician ordered a urinalysis, culture and sensitivity. A urinalysis is a group of physical, chemical, and microscopic tests. The tests detect and/or measure several substances in the urine, such as byproducts of normal and abnormal metabolism, cells, cellular fragments, and bacteria. The culture and sensitivity determines if any bacteria is present and the most effective medication to treat it. Further record review revealed the facility staff received the results of the culture and sensitivity on 1/5/19 at 1:32 PM; however, failed to notify the CRNP until 1/6/19, at which time an antibiotic was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-09 · tag F0697 — failed to manage pain — isolatedProvide safe, appropriate pain management for a resident who requires such services.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview it was determined the facility staff failed to thoroughly assess the need for pain medication for Residents (#16). This was evident for 1 of 2 resident selected for pain assessment and 1 of 25 residents selected for review during the annual survey. The findings include: Pain is often regarded as the fifth vital sign regarding healthcare because it is accepted now in healthcare that pain, like other vital signs, is an objective sensation rather than subjective. As a result, nurses are trained and expected to assess pain. A component of pain assessment-focusing on words to describe pain, intensity, location, duration, and aggravating or alleviating factors. It is the expectation the facility staff assess pain prior to and after the administration of pain medication to determine the need of the medication and the effectiveness of the medication. Medical record review for Resident #16 revealed on 5/4/18 the physician ordered: Hydrocodone-Acetaminophen, 5-325 milligrams by mouth every 6 hours for pain as needed. Hydrocodone-Acetaminophen is…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-04-09 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — the official record, unedited, may be distressing
Based on medical record review and staff interview, it was determined the facility staff failed to act upon the consultant pharmacist recommendation in a timely manner for Resident (#5). This was evident for 1 of 5 residents selected for unnecessary medication review during the annual survey process. The findings include: Medical record review for Resident #5 revealed the consultant pharmacy was in the facility and made recommendation addressed to the Director of Nursing on 3/6/19; however, the facility staff failed to address that recommendation until 4/4/19 upon surveyor inquiry. Interview with the Director of Nursing on 4/9/19 at 1:30 PM confirmed the facility staff failed to address the recommendation by consultant pharmacist for Resident #5 in a timely manner.
- Potential for harm · D2019-04-09 · tag F0790 — failed to provide dental care — isolatedProvide routine and 24-hour emergency dental care for each resident.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of a medical record and staff interview, it was determined the facility staff failed to take steps to ensure that a resident received dental services as ordered by the resident's physician. This was evident for 1 (Resident #12) of 4 residents reviewed during an annual recertification survey for dental services and 1 out of 25 selected for review during the annual survey process. The findings include: Medical record review for Resident #12 revealed on 2/21/19 the physician ordered: dental consultation; however, there is no evidence the consultation was ordered or obtained for Resident #12. It is the expectation that nursing staff take steps to obtain physician ordered consults. Interview with the Director of Nursing on 4/9/19 at 1:30 PM confirmed the facility staff failed to obtain a dental consultation for Resident #12 as ordered by the physician.
- Potential for harm · D2019-04-09 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (#16). This was evident for 1 of 25 residents selected for medical record review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. Medical record review for Resident #16 revealed on 5/14/18 the physician ordered: Hydrocodone-Acetaminophen, 5-325 milligrams by mouth every 6 hours as needed for pain. Hydrocodone is an opioid pain medication. Acetaminophen is a less potent pain reliever that increases the effects of hydrocodone. The combination of acetaminophen and hydrocodone is used to relieve moderate to severe pain. Review of the Medication Administration Record (MAR) revealed the facility staff documented the resident's pain level as 0 on: 2/8/19 at 7:30 PM, 2/26/19 at 7:15 PM, 2/27/19 at 7:15 PM and 3/2/19…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$15,440 in federal fines across 1 penalty.
- $15,440 — penalty dated 2024-02-23
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 ACTS RETIREMENT-LIFE COMMUNITIES — 27 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 4.7 | +0.3 vs chain |
| Health inspection | 5 of 5 | 4.4 | +0.6 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
The other 26 homes this chain runs (chain average 4.7★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ACTS ACQUISITION AND DEVELOPMENT COMPANY LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| ACTS ALLIANCE MANAGEMENT LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| ACTS LEGACY FOUNDATION, INC. | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| ACTS RETIREMENT SERVICES, INC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| ACTS SIGNATURE COMMUNITY SERVICES INC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| BONITA SPRINGS RETIREMENT VILLAGE INC | Organization | INDIRECT OWNERSHIP INTEREST | since 11/01/2024 |
| MEASE LIFE INC | Organization | INDIRECT OWNERSHIP INTEREST | since 10/01/2023 |
| CHRISTIANSEN, KAREN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| DETWEILER, HAROLD | Individual | CORPORATE DIRECTOR | since 12/31/2022 |
| FORREST, ANNE | Individual | CORPORATE DIRECTOR | since 12/31/2022 |
| GRANT, GERALD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| KELLY, MICHAEL | Individual | CORPORATE DIRECTOR | since 12/31/2022 |
| LAWSON, DANIEL | Individual | CORPORATE DIRECTOR | since 12/31/2022 |
| NEARY, ANNE | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| PAQUETTE, ELLEN | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| AHERN, SUSAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| FOX, GLENN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| GRANT, JONATHAN | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| VALDIVIA, PEGGY | Individual | CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| ACTS COMMUNITIES OF MARYLAND, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/31/2022 |
| ACTS MANAGEMENT SERVICES, INC. | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/06/2025 |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 02/06/2025 |
| KURZ, STELLAH | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| U.S. BANK | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | since 07/09/2025 |
| BAKER TILLY ADVISORY GROUP LP | Organization | ADP OF THE SNF | since 02/03/2025 |
| BAKER TILLY US LLP | Organization | ADP OF THE SNF | since 11/05/2024 |
| KNAISH, KINAN | Individual | ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 46 rows in the source record cover these 27 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.
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.
This home reported $800K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
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
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.
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 215235. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-12-11, 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.