Residences At Vantage Point
5400 Vantage Point Road, Columbia, MD 21044 · Non profit - Corporation · 44 certified beds · (410) 964-5454 Medicare only — no Medicaid
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (17% vs 45% nationally) — better care continuity
- 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
- 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
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 | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 5 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 5 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 17.6% | 20.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 3.0% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 0.0% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 10.2% | 22.8% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 1.9% | 2.4% | 3.3% | better |
| Long-stay residents on antianxiety or hypnotic medication | 13.6% | 16.7% | 18.9% | better |
| Long-stay residents with pressure ulcers | 7.4% | 5.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 20.6% | 25.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 44.1% | 13.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 2.7% | 1.1% | 1.4% | worse |
| Short-stay residents given the seasonal flu vaccine | 94.6% | 80.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 0.0% | 21.0% | 22.6% | check this* — see note marked star below the table |
| Short-stay residents with an outpatient ER visit | 4.4% | 9.8% | 12.0% | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
57.9% 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 66 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 80.5% 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 41 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.56 therapist hours per resident per day in 2026Q1 — more than 86% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 8% 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 | 57.9%CMS range 48.2–66.8 | 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 | 11.5%CMS range 7.4–17.6 | 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 | 80.5% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 63.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 70.7% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 7.6%CMS range 4.0–14.2 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.77 | 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 44 beds and averages 19.4 residents a day — about 44% occupied, or roughly 25 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 5.18 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.55 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.69 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 4.75 hrs/resident/day on weekends vs 5.36 on weekdays — 11% thinner on weekends. RN hours go from 1.66 to 1.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 17% is below the national median of 45%. 2 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.
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 more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.
- Potential for harm · E2026-03-19 · tag F0756 — failed to review each resident's drug regimen — patternEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and staff interview it was determined that the facility failed to develop and implement policies and procedures for medication regimen reviews, as evidenced by 1) failing to ensure that pharmacist identified irregularities reviewed by the attending physician, along with the action taken or not taken including rationale, was documented in the resident's medical record, and 2) failing to ensure medication irregularities were identified during monthly medication regimen reviews. This was evident for 4 (#6, #5,#16, #13) of 5 residents reviewed for unnecessary medication.The findings include: 1) On 3/11/26 at 2:45 PM, a review of Resident #6's February 2026 Medication Administration Record (MAR) revealed a 1/31/26 physician order for Metoprolol (lowers blood pressure) ER (extended release) by mouth one time a day for hypertension (HTN) (high blood pressure (BP)), hold for systolic (S) (top BP number) less than 110, or Pulse (P) less than 60 that documented Resident #6 received the Metoprolol every day in February. There was no documentation in the MAR to indicate…
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 · D2026-03-19 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview, it was determined the facility staff failed to reveal evidence that the resident or resident representative was informed of their right to formulate an advanced directive, and failed to ensure that a current copy of a resident's advance directive was in the resident's medical record. This was evident for 3 (#5, #12, #4) of 11 residents reviewed for advanced directives. The findings include: Advanced Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law related to provision of health care when the individual are not able to make their own decisions. 1) On 3/10/26 at 11:50 AM, a review of Resident #5's paper medical record failed to reveal an advance directive for Resident #5. Review of the electronic medical record (EMR) on 3/13/26 at 11:07 AM revealedResident #5 resided in the SNF since March 2023, and no documentation was found in the EMR to indicate the resident had an advance directive, whether the resident/representative was informed of the right to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-19 · 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 record review and interview it was determine the facility staff failed to notify the physician when a resident was identified to have a significant weight loss. This was evident for 1(#13) of 5 residents reviewed for Nutrition.The findings include:Resident #13's medical record was reviewed on 3/10/26 at 1:12 PM. The resident's weight record in the EMR (Electronic Medical Record) revealed that on 12/5/25 the resident weighed 320 lbs.(pounds). No weights were recorded for January or February 2026. Resident #13's next documented weight was 3/4/26 by Staff #4 the MDS nurse. The resident's weight at that time was 281.8 lbs. It was checked and recorded again the next day 3/5/26, as 281.8 lbs. by Staff #6 an LPN (Licensed Practical Nurse). The weights obtained on 3/4/26 and 3/5/26 reflected a 38.2 lb. or 11.94% significant weight loss over 3 months. A weight change note was written on 3/5/26 by the DON (Director of Nursing) for Weight Warning and reflected Resident #13's significant weight loss and included Dietitian will address, will have him/her on weekly weight. A Quarterly…
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 before2026-03-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review and staff interview it was determined that the facility failed to develop and implement comprehensive resident person-centered care plans with measurable goals and interventions. This was evident for 1 (#18) of 3 resident's reviewed for respiratory care, and 2 (#6, #5) of 5 residents reviewed for unnecessary medications.The findings include: The MDS (Minimal Data Set) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1.) On 3/9/26 at 11:53 AM the surveyor observed Resident #18 lying in bed wearing a nasal cannula (NC). A nasal cannula is a tube used to administer oxygen through the nose. The cannula was connected to an oxygen concentrator (a machine that concentrates and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-19 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview it was determined the facility staff failed to ensure that each resident received necessary respiratory care and services consistent with professional standards of practice by failing to administer oxygen at the prescribed rate, failing to assess and document the resident's immediate and ongoing need for, provision of and response to supplemental oxygen. This was evident for 1 (#18) of 3 residents reviewed for Respiratory Care.The findings include:On 3/9/26 at 11:53 AM the surveyor observed Resident #18 lying in bed wearing a nasal cannula (NC) - a tube used to administer oxygen through the nose. The cannula was connected to an oxygen concentrator - a machine that concentrates and delivers oxygen from room air. The concentrator was set to deliver oxygen at 3 L/min (Liters per minute). Review of Resident #18's medical record on 3/13/26 at 11:21 AM revealed a physician's order for Oxygen at 2L/min via NC as needed for SOB (shortness of breath); not 3L/min as observed by the surveyor. The order for 2L/min was included on Resident #18's…
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 · D2026-03-19 · tag F0710 — isolatedObtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on a review of the medical record and interview with staff it was determined that the facility failed to ensure that the physician addressed a significant weight gain/weight loss. This was evident for 1 (#3) of 5 residents reviewed for weight gain/weight loss.The findings include:On 3/12/26 at 9:30 AM, a review of Resident #3's medical record revealed, in a weight tracking system report, Resident #3's weight was documented as 181 pounds on 2/24/26 and 195 pounds on 3/1/26, which was a 7.7 % weight gain in 8 days. Further, the record review revealed that the dietician did not document in the medical record that the resident had a 7.7% gain in 8 days, and no other follow-up was noted by the dietician in the medical record.Continued review of the medical record failed to reveal that the physician did not evaluate and addressed the resident's significant weight gain when it was identified. Progress notes were reviewed in the medical record on 3/9/2026, with no mention of a 7.7% weight gain for Resident #3.On 3/12/26 at 10:40 AM during an interview, the Administrator Director…
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 · D2026-03-19 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to follow physician orders to follow blood pressure and pulse parameters for administering a blood pressure medication. This was evident for 1 (#6) of 5 residents reviewed for unnecessary medications. The findings include: On 3/11/26 at 2:45 PM, a review of Resident #6's February 2026 Medication Administration Record (MAR) revealed a 1/31/26 physician order for Metoprolol Succinate (lowers blood pressure) ER (extended release) tablet by mouth one time a day for hypertension (HTN) (high blood pressure (BP)) and hold for systolic (S) (top number of BP) reading) less than 110, or Pulse (P) (heart rate) less than 60 that documented Resident #6 received the Metoprolol every day in February. There was no documentation in the MAR to indicate that prior to the administration of the metoprolol, Resident #6's BP and P were monitored and the metoprolol administered within the parameters of the physician's order. Review of 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 · D2026-03-19 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to keep complete and accurate medical records. This was evident for 5 (#4, #12, #11,#18, #16) of 10 residents reviewed for Advanced Directives and 1 (#13) of 5 residents reviewed for nutrition. The findings include Maryland Orders for Life Sustaining Treatment (MOLST) includes medical orders for Emergency Medical Services (EMS) and other medical personnel regarding cardiopulmonary resuscitation and other life-sustaining treatment options based on a patient's wishes. It is valid in all healthcare facilities and programs throughout Maryland. Section 1 includes orders to Attempt CPR or No CPR. Included in the No CPR section are three options: A-1 Intubate; A-2 Do Not Intubate but comprehensive efforts may include limited ventilatory support by CPAP or BiPAP; or Option B No CPR, Palliative and Supportive Care. Section 2 to 9 have options for situations other than cardiopulmonary arrest. Per the MOLST instructions:…
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 before2026-03-19 · tag F0880 — failed to prevent and control infections — isolatedProvide 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, record review, and interview it was determined the facility staff failed to ensure respiratory care equipment was 1) properly date labeled, and 2) cleaned and stored as per the manufacturer's instructions. This was evident for 2 (#18 and #13) of 3 residents reviewed for Respiratory Care.The findings include: 1) On 3/9/26 at 11:53 AM the surveyor observed Resident #18 lying in bed wearing a nasal cannula (NC) (a tube used to administer oxygen through the nose). The cannula was connected to an oxygen concentrator (a machine used to concentrate and deliver oxygen from room air). A piece of white tape was attached to the nasal cannula tubing with the date 3/1/26 in black marker. Another observation on 3/17/26 at 9:06 AM revealed Resident #18's nasal cannula tubing had no date label. On 3/17/26 at 10:45 AM Staff #7 an LPN (Licensed Practical Nurse) observed the resident in his/her room with the oxygen running via NC and confirmed the nasal cannula was not labeled. She indicated that she did not know why the tubing wasn't labeled. Review of Resident #18's medical…
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 · F2024-12-13 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, interviews and facility record review it was determined the facility failed to ensure food handling practices were followed in accordance with professional standards for food service safety, ensure the dishwashing system met the required minimum temperatures and chemical concentration, ensure monitoring of dishwasher chemical concentration and food service equipment functioning, ensure thorough environmental cleaning of the kitchen, and ensure the monitoring of food temperatures and food storage. These deficient practices have the potential to affect all residents. The findings include: On 12/2/24 at 8:00AM during the surveyor's initial tour of the facility's kitchen the surveyor noted the following signage was present: Attention team! All food items must have the following: label, date, item covered. On 12/2/24 at 8:03AM during the surveyor's initial tour of the facility's kitchen the surveyor noted the following signage present on the facility's walk-in refrigerators/freezers: All product stored in this walk-in must be: covered, labeled, dated, any product…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 16 citations
- Potential for harm · E2024-12-13 · tag F0583 — failed to protect personal privacy — patternKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview it was determined the facility failed to ensure privacy of protected health information was maintained for residents of the facility (#8, #16, #12, #122, #2, #3, #11, #14, #7, #1, #17). This was evident for 11 out of 21 residents during the facility's recertification/complaint survey. The findings include: On 12/11/24 at 3:13 PM surveyors observed an unlocked, unattended monitor screen in the resident hallway which displayed the photo images of 11 residents of the facility (#8, #16, #12, #122, #2, #3, #11, #14, #7, #1, and #17) with their medical record numbers listed next to their photo images. The monitor screen also displayed various tabs and applications. Geriatric Nursing Assistant (GNA) #12's name was observed on the screen. On 12/11/24 at 3:17 PM surveyors observed GNA #12 enter the resident hallway at which time surveyors shared their concerns and conducted an interview. GNA #12 observed the concern and stated the following during the interview: Okay, let me close it. On 12/11/24 at 3:18 PM surveyors requested a dual observation of the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-12-13 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and record review it was determined the facility failed to timely report an injury of unknown origin to the Office of Health Care Quality. This was evident for 2 (#MD00200761, and #MD00162737) out of 2 facility reported incidents reviewed for injuries of unknown origin for Resident #220 during the facility's recertification/complaint survey. The findings include: 1.) On 12/6/24 at 8:22AM the surveyor requested the complete investigation file for facility self-report #MD00200761 from the facility's Administrator. On 12/6/24 at 8:42AM the surveyor received the investigative file from the Administrator who confirmed this was the complete investigation file. Review of the facility's initial self-report revealed Resident #220's hip fracture was reported as an injury of unknown source to the Office of Health Care Quality on 12/19/23 at 10:30AM. Review of the follow-up self-report revealed the following information was documented: Resident had a fall on 11/28/23 from his/her wheelchair. On 12/10/24 at 9:58 AM the surveyor conducted a review of the medical record of…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-12-13 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview it was determined the facility failed to ensure a thorough investigation was performed for an injury of unknown origin. This was evident during the surveyor's review of facility reported incident #MD00200761 reviewed by the surveyor during the facility's recertification/complaint survey. The findings include: On 12/6/24 at 8:22AM the surveyor requested the complete investigation file for facility self-report #MD00200761 from the facility's Administrator. On 12/6/24 at 8:42AM the surveyor received the investigative file from the Administrator who confirmed this was the complete investigation file. Review of the facility's initial self-report revealed Resident #220's hip fracture was reported as an injury of unknown source to the Office of Health Care Quality on 12/19/23 at 10:30AM. Review of the follow up self-report revealed the following information was documented: Resident had a fall on 11/28/23 from his/her wheelchair. On 12/10/24 at 9:58AM the surveyor conducted a review of the medical record of Resident #220 which revealed the following 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 · Dcited before2024-12-13 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview with residents, review of resident medical records, and interview with facility staff, it was determined that the facility failed to hold care plan meetings at least quarterly. This was evident for 1 (Resident #17) of 1 resident reviewed for care planning during the recertification/complaint survey. The findings include: On 12/03/24 at 03:02 PM, Resident #17 was interviewed. During the interview, the resident indicated that s/he did not recall ever being invited to a care plan meeting but would like to attend one. On 12/12/24 at 10:34 AM, Resident #17's medical record was reviewed. The review revealed that the resident was admitted to the facility in June, 2024. The review failed to reveal evidence that a care plan meeting was held after the initial care plan meeting in June. On 12/12/24 at 11:16 AM, the Health Center Social Worker (SW) #9 was interviewed. During the interview, SW #9 indicated that residents should receive a care plan meeting on admission and quarterly. She stated that she creates a sign-in sheet for the meeting, a letter inviting the resident's…
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 before2024-12-13 · tag F0880 — failed to prevent and control infections — isolatedProvide 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 during medication administration it was determined that the facility failed to follow infection control practices consistent with accepted standards of practice. This was evident for 3 (Residents #5, #10 and #13) of 4 residents reviewed for medication administration during the recertification/complaint survey. The findings include: On 12/06/24 at 8:17AM, surveyors observed LPN #10 drop Resident #5's medication bottle on the floor in the hallway on Cedar Place. LPN #10 picked up the medication bottle for Resident #5 off the floor and placed the medication bottle back in Resident #5's medicine drawer in the medication cart without sanitizing the medicine bottle or their hands. On 12/06/24 at 8:35AM, surveyor observed LPN #10 give Resident #5 their medications and leave Resident #5's room without sanitizing their hands. LPN #10 then retrieved the Blood Pressure (BP) cuff from the hallway on Cedar Place and entered Resident #13's room and took Resident #13's blood pressure. On 12/06/24 at 9:19AM, LPN #10 went to get another computer because the computer on 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 · D2019-12-05 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interviews with the resident family and facility staff it was determined the facility failed to ensure that the appropriate equipment used to transfer a resident who receives dialysis was in place prior to the resident going to the scheduled dialysis appointment. This was found to be evident for 1 resident (Resident # 9) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: An interview was conducted with Resident # 9's family representative Responsible Party (RP) on 12/2/19 at 12:10 PM to discuss concerns regarding the resident. The RP stated that on 11/11/19 the resident missed his/her scheduled dialysis appointment because the nurse improperly placed a sling that could not be used to transfer the resident at the dialysis facility. An interview was conducted with the Nursing Home Administrator (NHA) on 12/4/19 at 10:29 AM and she was asked about the resident not receiving dialysis on 11/11/19. The NHA stated that she recalled that this did occur. The NHA went on to say that the nurse who cared for the resident on…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-05 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview it was determined the facility failed to conduct a thorough investigation of a fracture of unknown origin sustained by a functionally and cognitively impaired resident (Resident #7). This was evident for 1 of 3 residents reviewed for resident's rights during this annual recertification survey. The findings included: The facility failed to thoroughly investigate the circumstances of a fracture sustained by Resident #7. Medical record review on 12/2/19 revealed that Resident #7 was a long-term care resident with diagnoses that included but were not limited to Cerebrovascular Accident (stroke), Muscle Weakness, Aphasia, a history of repeated Falls and Advanced Dementia. Review of facility reported incident #MD00133588 revealed that on 11/12/18 Geriatric Nursing Assistant (GNA) #3 noted that Resident #7 had swelling and discomfort to the right ankle. An x-ray confirmed that the resident had an acute fracture of the ankle. The facility report noted that Resident #7…
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 · D2019-12-05 · 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 — 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 interviews with the resident family and facility staff, it was determined the facility failed to notify the resident and/or family representative in writing that they were being transferred out of the facility to the hospital and the reason for the hospital stay. This was evident for 2 (Resident # 24 and Resident # 9) of 3 residents reviewed for hospitalization during the facility's annual Medicare/Medicaid survey. The findings include: 1. An interview was conducted with the resident representative (RP) on 12/2/19 at 12:10 PM and they stated that Resident # 9 went out to the hospital on [DATE] and the facility did not provide him/her with any documentation about the transfer. An interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 12/4/19 at 9:55 AM and they were asked to provide a copy of the written transfer summary that was sent with the resident and that was given to the resident representative upon transfer to the hospital…
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 · D2019-12-05 · 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 — the official record, unedited, may be distressing
Based on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 1 (# 24) of 3 residents reviewed for hospitalization. The findings include: Review of Resident #24's medical record on 12/5/19 at 11:49 AM revealed that on 4/6/19 at 8:20 PM the resident was transferred to the hospital for an evaluation of a possible seizure. Medical record documentation revealed that the responsible party was called, however, there was no written documentation that the responsible party was notified in writing of the bed-hold policy. During an interview with the Director Of Nursing on 12/5/19 at 3 PM, she stated, the transfer/discharge information is included in the admission packet. When given the citation tag by this surveyor, the DON stated the information will now be given for all residents transferred or discharged from the facility.
- Potential for harm · D2019-12-05 · tag F0637 — isolatedAssess the resident when there is a significant change in condition
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined facility staff failed to conduct a comprehensive assessment when a significant decline occurred in the Resident #19's condition. This was evident for 1 of 3 residents reviewed for a change in condition during this annual recertification survey. The Minimum Data Set (MDS) is a comprehensive assessment of the resident completed by the facility staff. The MDS is a multi-disciplinarian tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain and medications to name a few] to be addressed. The MDS assessment directs the facility staff on issues that may need to be addressed. The findings include: Medical record review revealed that Resident #19 was admitted to the facility with diagnoses that included but were not limited to Dementia, history of Falls, Abnormal Loss of Weight, Congestive Heart failure and Chronic Kidney Disease. Review of the annual MDS…
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 · D2019-12-05 · tag F0642 — isolatedEnsure a qualified health professional conducts resident assessments.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interviews with facility staff it was determinedthat the facility failed to complete the discharge Minimum Data Set (MDS). This was found to be evident for 1 resident (Resident # 2) when assessments were triggered to be reviewed during the facility's annual Medicare/Medicaid survey. The findings include: The MDS forms the foundation of a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status. Review of the discharge MDS on 12/3/19 at 3:12 PM revealed that Resident # 2 was discharged on 7/8/19 to the Assisted Living Unit (ALU). Review of the discharge note on 7/8/19 confirmed that the resident was discharged . The facility missed opening and completing the discharge MDS. An interview was conducted with the MDS Coordinator on 12/4/19 at 1:42 PM and he stated that he reviewed the MDS and is unsure why the MDS discharge was not done. The Nursing Home Administrator (NHA) and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-05 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview it was determined the facility failed to develop and implement an individualized care plan that addressed the use of Paxil and Lorazepam for Resident #11. Also, it was determined the facility failed to develop comprehensive person-centered care plan for Resident #4 receiving two antidepressant medications. This was evident for 2 of 3 (R#4 & R#11) residents reviewed for care plan implementation during this annual recertification survey. The findings include: 1) The facility failed to develop care plans that clearly identified target symptoms for the use of Paxil and Lorazepam. Medical record review on 12/4/19 revealed that Resident #11 was a long-term care resident with diagnoses that included but were not limited to Anxiety Disorder, Recurrent Depressive Disorder and Dementia. The medical record contained a care plan with a goal date of 12/24/19 with a problem statement that the resident was receiving antianxiety drugs on a regular basis. Target symptoms or the resident's expressions of anxiety were not specified. Interventions…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-12-05 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interviews with the resident family and facility staff it was determined the facility failed to update a resident's care plan to include non-compliance with treatment regimen. This was evident for 1 resident (# 9) reviewed during the facility's annual Medicare/Medicaid survey. The findings include: An interview was conducted with the Resident Representative (RP) on 12/2/19 at 12:10PM to discuss concerns regarding Resident # 9. The RP stated that Resident # 9 missed a dialysis appointment on 11/11/19. The RP went on to say that the nurse improperly placed a sling on Resident # 9 and the resident had to be brought back to the facility and did not receive dialysis. An interview was conducted with the NHA on 12/4/19 at 10:29 AM and when asked about the resident missing a dialysis appointment, she stated that this did occur but also indicated that the resident has refused to go to dialysis previously. Review of the care plan on 12/4/19 revealed that Resident # 9 does not have a non-compliance care plan. In another interview with the DON on 12/4/19 at…
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 · D2019-12-05 · tag F0732 — isolatedPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview it was determined the facility staff failed to prominently post nurse staffing information to ensure that staff and visitors could easily identify staff to resident assignments. This was evident for the long-term care unit throughout this annual recertification survey. The findings include: During an initial tour of the facility on 12/2/19 at 10:10 AM the surveyor noted the staffing sheet was in a plastic photo type frame at the nurses' station. The placement of the assignment sheet was not obvious, and it was necessary to go beyond the nurses' station desk to view the assignment sheet. Subsequent observations on 12/3/19 at 8:30 AM, 12/4/19 at 11:30 AM and 12/5/19 at 8:45 AM also revealed that he assignment sheet was not posted in a size and format to permit easy reading and was not immediately visible to residents and visitors. The findings were discussed with the Director of Nursing on 12/5/19 at approximately 1:15 PM.
- Potential for harm · D2019-12-05 · tag F0943 — isolatedGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of employee files, training records and staff interview it was determined the facility failed to consistently ensure that all staff received abuse prevention training that included activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property and Dementia management. This was evident for 2 of 4 nurses reviewed for training compliance during this annual recertification survey. The findings include: Surveyor review of a facility reported incident #MD00133588 revealed a concern about a fracture of unknown origin. The resident was diagnosed with an acute fracture of the right ankle. Surveyors often review training records of staff assigned to residents noted to have injuries of unknown origin. Review of the training records for Licensed Practical Nurse (LPN) #2, who was assigned to the resident's care on the date the injury was reported, revealed s/he did not receive the required abuse prevention and Dementia Management…
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 · D2019-12-05 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of employee files, training records and staff interview it was determined that the facility failed to ensure that all nurses' aides received 12 hours of training, annually, that included abuse prevention and Dementia management, and addressed areas of weakness as determined in the nurse aides' performance reviews. This was evident for 3 of 7 (GNA # 1, 2 and 3) nurses' aides reviewed for training compliance during this annual recertification survey. The findings include: Surveyor review of a facility reported incident #MD00133588 revealed a concern about a fracture of unknown origin. The resident was diagnosed with an acute fracture of the right ankle. Review of the employee file for Geriatric Nursing Assistant (GNA) #3, who was assigned to the resident's care on the date the injury was reported, revealed that s/he did not receive the required 12 hours of in-service training that included abuse prevention and Dementia Management. Further review of the facility's training records revealed that GNAs #1 and #2 did not have documentation of 12 hours of education, abuse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to LIFE CARE SERVICES — 43 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 | 4.1 | +0.9 vs chain |
| Health inspection | 4 of 5 | 3.7 | +0.3 vs chain |
| Staffing | 5 of 5 | 4.4 | +0.6 vs chain |
| Quality measures | 5 of 5 | 4.0 | +1.0 vs chain |
The other 42 homes this chain runs (chain average 4.1★, per CMS)
Showing 40 of 42; lowest-rated first.
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| BANK OF NY MELLON | Organization | 5% OR GREATER SECURITY INTEREST | since 04/12/2007 |
| BALKIN, DANIEL | Individual | CORPORATE DIRECTOR | since 01/01/2024 |
| BALOH, BRANDAN | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| BARRON, STEVE | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| BEDNARZIK, BARBARA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2024 |
| BRUETTE, LEO | Individual | CORPORATE DIRECTOR | since 01/01/2020 |
| CASTELLAN, SUSAN | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2008 |
| IMRE, VICTORIA | Individual | CORPORATE DIRECTOR | since 01/01/2023 |
| MARTIN, BRUCE | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2024 |
| MILES, FRANK | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| ROMANO, CAROL | Individual | CORPORATE DIRECTOR | since 01/01/2017 |
| THOMAS, VIRGINIA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER | since 01/01/2025 |
| WADE, JOHN | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| LIFE CARE SERVICES LLC | Organization | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 03/01/2000 |
| CAREY, PIERCE | Individual | OPERATIONAL/MANAGERIAL CONTROL | since 02/15/2023 |
| HITCHCOCK, ALEXIS | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/15/2025 |
| LAZRIS, ANDREW | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 04/14/2025 |
CMS files one row per role, so the 24 rows in the source record cover these 17 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.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. 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, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MD
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Maryland Medicaid page for homes that do.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215344. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-19, 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.