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Alice Byrd Tawes Nursing Home

201 Hall Highway, Crisfield, MD 21817 · Non profit - Corporation · 76 certified beds · (410) 968-1200 Medicare & Medicaid certified

Call the home — (410) 968-1200 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citations — no harm found (F0609, F0610) — most recent May 20261 actual-harm citation
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • 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
  • it has 1 actual-harm citation
  • a high number of inspection citations overall (31) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
4384 Crisfield Hwy · (410) 968-1800 · Call to confirm hours
Pharmacy
26427 Burton Ave · (410) 968-2300 · Call to confirm hours
Grocery
Food Lion0.5 mi
1 Jacksonville Rd · (410) 968-1321 · Call to confirm hours
Park
Wellington Beach And Park · Typically dawn to dusk
Place of worship

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 5 of 5
Long-stay residentspeople who live here 4 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 improved from 3 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.

Overall rating5★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased25.0%20.4%15.4%worse
Long-stay residents who lose too much weight3.7%5.4%5.4%better
Long-stay residents with a catheter left in their bladder1.0%0.5%0.9%typical
Long-stay residents with a urinary tract infection0.4%1.5%2.0%better
Long-stay residents with depressive symptoms1.6%22.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.9%2.4%3.3%better
Long-stay residents whose ability to walk worsened30.8%22.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication11.1%16.7%18.9%better
Long-stay residents given the seasonal flu vaccine100.0%96.6%95.3%typical
Long-stay residents with pressure ulcers4.6%5.9%4.7%typical
Long-stay residents with worsening bladder/bowel control24.4%25.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table11.9%13.8%17.1%better
Short-stay residents who newly got an antipsychotic medication0.5%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine97.4%80.6%79.4%better
Short-stay residents rehospitalized after admission13.7%21.0%22.6%better
Short-stay residents with an outpatient ER visit10.1%9.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.901.331.67better
Long-stay outpatient ER visits per 1,000 resident days1.061.201.80better

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.

58.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 151 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

58.7%U.S. median 51.5%
Got home and stayed home
9.8%U.S. median 10.7%
Went back to hospital
65.1%U.S. median 56.6%
Met the expected recovery
0.27U.S. median 0.31
Therapy hours / resident / day
0.12hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.02hours / resident / day
Speech therapy

Met the expected recovery: 65.1% 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 63 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 0.27 therapist hours per resident per day in 2026Q1 — more than 41% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF58.7%CMS range 51.4–66.051.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.8%CMS range 6.9–13.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge65.1%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge66.7%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge58.7%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened1.3%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.0%CMS range 3.0–9.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.741.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.10
RN hours/ resident / day
0.75
LPN hours/ resident / day
1.62
Aide hours/ resident / day
3.46
Total nurse hours/ resident / day
0.84
RN hoursweekends
41.3%
Total nursing turnover
36.8%
RN turnover

How full it usually is: this home is certified for 76 beds and averages 69.4 residents a day — about 91% occupied, or roughly 7 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.46 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 1.10 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 1.62 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.08 hrs/resident/day on weekends vs 3.62 on weekdays — 15% thinner on weekends. RN hours go from 1.21 to 0.84 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 41% is about the same as the national median of 45%.

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

Inspection trend

7
deficiencies at the latest standard inspection (2026-03-06)
13
at the previous standard inspection (2024-11-20)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

31 citations, most serious first. The 11 most serious are shown; the remaining 20 are one tap away and print in full.

  • Actual harm · G2019-09-20 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical records review and interview with staff it was determined that the facility staff failed to notify the physician when there was an acute change in the resident's condition after a fall. This was found to be true for 1 out of 22 residents (Resident #4) reviewed during the investigation stage of the long-term care survey process. This failure resulted in actual harm to Resident #4. The findings include: On 9/19/19 Resident #4's medical records were reviewed. This review revealed the resident was admitted to the facility in September 2018 for rehabilitation and with diagnosis that included cerebral infarction, or stroke (a brain lesion in which a cluster of brain cells die when they don't get enough blood), right hemiplegia (paralysis of the right side) and high blood pressure. Review of the medical records revealed on 4/5/19 the resident was found on the floor beside the bed. Review of the investigative reports revealed that the resident's nurse, licensed practical nurse (LPN) #22 indicated that the resident was assessed and put back into the wheelchair. Review of LPN…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-05-20 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined the facility failed to report an allegation of seclusion/abuse immediately or no later than 2 hours after the allegation was made aware to the facility's Administration team. This was evident for 1 (#4) out of 1 resident reviewed for allegations of abuse during the complaint survey. The findings include the following:Intake # 2964422 was reviewed on 5/20/26 at approximately 10:30AM for seclusion/ abuse allegations involving Resident #4.During an interview on 05/20/2026 at 11:40 AM with the Director of Nursing she stated, On 03/19/2026 there was an allegation of seclusion/abuse involving Resident #4, the facility investigated and the allegation was not substantiated. The facility provided the survey team with a copy of the investigation.Review of the investigation records on 05/20/2026 at 12:40 PM revealed that the facility was made aware of an allegation of seclusion/abuse involving Resident #4 on 03/19/2026 at 7:30 PM. Further review of records revealed that the facility did not report allegation to the Office of Health 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and facility staff interview, the facility staff failed to protect and value resident's dignity (Resident #38). This was evident for 1 out of 1 resident reviewed for dignity. The findings include: On 3/3/26 at 7:40am, the surveyor observed Resident #38 sitting in a wheelchair in front of the 2nd floor's nursing station attempting to get nursing staff's attention by stating excuse me repeatedly. The resident manually moved his/her wheelchair closer to the 2nd floor's nursing station and stated excuse me to LPN #17 which he/she was on the phone. LPN #17 ignored the resident. Infection Preventionist (IP) #14 walked past LPN #17 and the resident while the resident stated excuse me again. IP #14 also ignored the resident. The resident continued to attempt to get nursing staff's attention by excuse me without success. The closest nursing staff member to the resident was LPN #17 and LPN #17 continued to ignore him/her. When IP #14 re-entered the 2nd floor nursing station, the surveyor informed IP #14 that Resident #38 was requesting assistance. IP #14 asked the…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on random observations it was determined that the facility failed to maintain a homelike environment for the residents of the 3rd floor. This was evident for 1 of 2 units ( 3rd floor). The findings include:Upon entering the 3rd floor on 3/3/26 at 9:00 AM and entering the open sitting area, this surveyor observed that the television was on, however, there was a black bar covering half of the screen on the left side. The tour of the unit and observations continued throughout the morning. Returning to the unit at approximately 11:50 AM on 3/3/26 to review medical records, the same observations were made of the television on in the sitting room with the black bar covering half of the screen on the left side, with the same television game show on.Observations of the 3rd floor unit on 3/4/26 at 10:09 AM revealed the same observations of the television on with the black bar covering the left half of the screen, with the same television game show on. This surveyor sat in the sitting area to complete observations at this time. A popular game show was on, however, only the host could be…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status. This was found to be evident for 1out of 5 residents (R # 4) reviewed during the investigative stage of the survey.The findings include: The MDS 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. MDS assessments need to be accurate to ensure each resident receives the care they need.A review of the medical record on 3/4/26 at 4:50 PM for Resident #4 revealed a completed MDS on 1/17/26 identifying Resident #4 as receiving an insulin injection for 7 days during the lookback period. A concurrent review of the medication administration record (MAR) failed to reveal that Resident #4 received any insulin injections for this most recent look back period for the coded MDS completed on 1/17/26. Interview on 3/5/26 with staff #8 revealed that she was the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, medical record review and interview, the facility failed to monitor a resident's nutrition status and failed to recognize a resident's need for feeding assistance and inform the dietitian/physician. This was evident for 1 of 2 residents (Resident #8) reviewed for nutrition. The Findings include: On 3/3/26 at 8:00am, the surveyor observed Resident #8 during breakfast attempting to feed him/herself. The resident was having difficulties with putting the food in his/her mouth due to tremors in the hands. The surveyor attempted to interview the resident, but the resident was lethargic and difficult to understand. On 3/3/26 at 8:35am, the surveyor interviewed GNA #12 regarding Resident #8's status and his/her ability to feed him/herself. GNA #12 stated that the resident was able to feed him/herself. The surveyor pointed out that the resident was observed having trouble feeding her his/herself due to tremors in the hands. GNA #12 stated that the resident normally picks at (his/her) food and requires no assistance with feeding. On 3/4/26 at 8:20pm, the surveyor…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-06 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services 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, staff interview and review of facility policy, it was determined that the facility failed to maintain ongoing communication with the dialysis facility. This was evident during the review of 1 of 1 Residents (#11), (all residents) who currently attend dialysis. The findings include:Review on 3/3/26 of the medical record for Resident #11 revealed that s/he currently received dialysis and according to the matrix provided to the survey team s/he is the only resident currently receiving dialysis.A review of the dialysis communication pages in the binder revealed inconsistencies in the completion of the assessments for each visit to dialysis and the return to the facility from dialysis. Interview with LPN #17 on 3/5/26 at 11:00 AM regarding the dialysis communication book, and process revealed that the assigned dialysis book goes with the resident to the dialysis center. LPN #17 was asked about the form with the 3 sections, she reviewed the book and said that dialysis needs to fill out the middle section, and the night shift does the top, she was not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0812 — failed to store, cook, and serve food safely — isolated
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interviews of facility staff, it was determined that food service employees failed to ensure that sanitary practices were followed and safe food handling practices were followed to reduce the risk of foodborne illness. This was evident during the initial tour of the kitchen and only 1 observation. The findings include:During the tour of the kitchen and observation of staff practices, this surveyor observed the following at 3/3/26 at 8:16 AM: On the cold prep table a large metal container holding milk was sitting unattended. Within arm's reach of the container of milk was an open bottle of water, a coffee cup and a personal black thermos with red hearts on it. Additionally, there was a white rag sitting next to and touching the metal pan of milk with orange, brown and black stains and flecks of debris.At 8:18 AM staff #9, the lead cook was notified of the observations and concerns and directed the staff to discard the container of milk, he had already removed the personal drinking items when he saw this surveyor making observations and notations. On 3/4/26 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-03-06 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews it was determined that the facility failed to ensure medical records were complete and accurate. This was evident for 1 (Resident #5) of 1 Residents reviewed for complete and accurate medical record documentation.The findings include:During a review of the Task Administration Record (TAR) for Resident #5 on 3/06/2026 at 7:51 AM it was discovered that Resident #5 had orders for wound care that was not signed off as being completed. The orders include:An order for Clean left buttock open area with Normal Saline Solution and cover with AG and dry sterile dressing was not signed off as completed on 2/23/2026.An order for Clean right calf open area with Normal Saline Solution, pat dry and cover with damp AG and dry sterile dressing every dayshift for wound care was not signed off as completed on 2/23/2026.An order to Clean wound to right outer elbow with Normal Saline Solution, pat dry, cover with Xeroform and dry sterile dressing was not signed off as completed on 2/23/2026.During an interview with the Director of Nursing (DON) on 3/06/2026 at 9:05…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-20 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of reporting data, clinical records and interview it was determined that the facility staff failed to ensure assessments were sent to the Centers for Medicare and Medicaid Services as required. This was evident for 4 (#11, #51, #56, and #69) out of the 7 residents reviewed for late reporting. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. A review of seven residents' clinical records was conducted secondary to the survey process triggering this task for missing resident assessments. Records for Residents #11, #51, #56, #62, #63, #67, and #69 were reviewed on 11/20/24. The electronic health records revealed that some of the residents had an assessment that was listed as in progress. The MDS director was interviewed on 11/20/24 at 9:39 AM. She was provided with the names of the residents…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-11-20 · tag F0655 — pattern
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of medical records and interview with facility staff, it was determined that the facility failed to provide a baseline care plan summary to residents and/or resident's representative within 48 hours after admission. This was evident for 6 (#57, #8, #19, #36 # 30, and #10) out of 12 residents reviewed for baseline care plans during the recertification survey. The findings include: A baseline care plan (BLCP) must be completed within 48 hours of a resident's admission to the facility and include the initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. A summary of the BLCP as well as a list of the resident's current medications must be given to each resident and/or his/her representative. Completion and implementation of the BLCP is intended to promote continuity of care and communication among staff, increase resident safety, and safeguard against adverse events (undesirable outcomes) that can occur right after admission. 1.) On 11/18/24…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
Show the remaining 20 citations
  • Potential for harm · E2024-11-20 · tag F0732 — pattern
    Post nurse staffing information every day.
    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 post required staffing information. This was evident for 3 out of 3 floors of the facility during the recertification survey. The findings include: On 11/12/24 at approximately 10:15AM surveyors entered the building for the facility's recertification survey and upon entering, no staffing information was observed posted on the first floor. On 11/12/24 at 11:47AM the surveyor conducted a tour of the facility's second floor nursing unit. Observation of a dry erase board on the unit revealed there was no facility name displayed, the following date was observed: November 1, 2024, there was no total number of staff displayed, and no actual hours worked listed by category for 7 out of 11 nursing staff. No other postings of staffing information were observed to be present on the unit. On 11/12/24 at 12:04PM the surveyor conducted a tour of the facility's third floor nursing unit. Observation of a dry erase board on the unit revealed there was no facility name displayed, there was no total number of staff displayed,…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-11-20 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, it was determined that the facility failed to properly store, date, and label food items to prevent food from being served that may be unsafe to eat and to prevent cross contamination. This was evident by the initial kitchen observations of the facility's dessert freezer during the recertification survey. The findings include: On 11/12/24 at 10:55 AM during the initial kitchen observation the surveyor entered the kitchen and spoke with the Food Service Supervisor (FSS) #22. Together a walkthrough of the refrigerator and freezers was conducted. During the inspection of the freezer, which had frozen desserts inside, the surveyor noticed a large full bag of brownies in a clear Ziplock bag and a large full bag of cookies in a clear Ziplock bag. This was brought to FSS #22's attention and they removed the bags of brownies and cookies and placed them on a stainless-steel counter in front of the dessert freezer. When asked how long the brownies and cookies had been in the freezer, FSS #22 said: I am not sure. FSS #22 then called over Dietary Aide #23…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-20 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to ensure advance directives for a resident were maintained and readily retrievable by any facility staff in their medical record. This was evident for 1 (Resident #50) out of 4 residents reviewed for advanced directives during the facility's recertification survey. The findings include: On 11/13/24 at 8:51AM the surveyor observed and reviewed the medical record which included both the hard chart and electronic health record for Resident #50 which revealed that a living will and power of attorney was documented for the resident, however, no evidence of the living will or power of attorney documents could be found within the medical record of the resident. The surveyor noted upon review of the resident's Maryland Medical Orders for Life Sustaining Treatment form that it referred to the resident as having a healthcare agent, however, no advanced directives were present within the resident's medical record. On 11/14/24 at 10:43AM the surveyor reviewed the medical record which revealed a physician'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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-20 · tag F0637 — isolated
    Assess the resident when there is a significant change in condition
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the medical record and interview with facility staff, it was determined that the facility failed to document in the medical record when the determination was made that a resident met the criteria for a Significant Change in Status Assessment (SCSA). This was evident for 1 (Resident #24) out of 33 residents reviewed during the recertification survey. The findings include: A Significant Change in Status Assessment (SCSA) is a comprehensive assessment that must be completed within 14 days after the Interdisciplinary Team (IDT) has determined that a resident meets the guidelines for significant change for either major improvement or decline. On 11/18/24 at 8:09AM review of the facility's Change in a Resident's Condition or Status policy revealed, A significant change of condition is a major decline or improvement in the resident's status that: a.Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions (is not self-limiting); b.Impacts more than one area of the resident's health status; c.Requires…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, record review and interview it was determined the facility failed to ensure a resident's care plan was comprehensively developed and person centered. This was evident for 1 (Resident #50) out of 1 resident reviewed for activities during the facility's recertification survey. The findings include: On 11/12/24 at 11:27AM the surveyor observed residents of the unit engaged in the community area, however, Resident #50 was observed to be in their bed awake with no activity materials observed within reach of the resident. On 11/13/24 at 9:18AM the surveyor observed Resident #50 in bed sleeping, and no activity materials were observed within reach of the resident. On 11/14/24 at 10:59AM the surveyor reviewed the medical record which revealed the resident had the following incomplete care plan intervention dated as initiated beginning on 3/14/24 for activities: Provide the resident with materials for individual activities as desired. The resident likes the following independent activities: (SPECIFY). On 11/14/24 at 11:01AM the surveyor conducted an interview with…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-20 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident interview, review of the medical record, and interview with facility staff, it was determined that the facility failed to hold care plan meetings for residents and/or their representatives at the time of their admission. This was evident for 1 (Resident #18) out of 33 residents reviewed during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. On 11/13/24 at 11:49 AM in an interview with Resident #18 she stated she had attended a care plan meeting since her admission to the facility. On 11/13/24 at 12:08PM review of the resident's paper chart did not reveal any documentation that care plan meetings had occurred. On 11/14/24 at 10:07AM review of Resident #18's medical record revealed the resident was admitted on [DATE] and that the resident had an admission MDS assessment completed on 2/12/24. Further review of the medical record revealed 2…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-20 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview and record review it was determined the facility failed to: 1) ensure and monitor the implementation of fall interventions, and 2) monitor for effectiveness of fall interventions. This was evident for 1(Resident #25) out of 2 residents reviewed for accidents during the facility's recertification survey. The findings include: On 11/13/24 at approximately 9:18AM the surveyor observed Resident #25, who was awake and laying in their bed. Upon interview of Resident #25 they expressed to the surveyor that they wanted to get up out of their bed and did not understand why they ate breakfast in their room instead of in the dining area. On 11/19/24 at 12:20PM the surveyor reviewed the medical record of Resident #25 which revealed they had extensive fall history, including four recent falls in October 2024. Review of the resident's care plan revealed the resident was at high risk for falls, and after a fall on 10/15/24 and a fall on 10/18/24, the following intervention was not implemented until 10/24/24 and was to currently be in place: low bed with mat when 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-20 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure the implementation of a nutrition intervention for a resident to prevent further weight loss. This was evident for 1 (Resident #53) out of 3 residents reviewed for nutrition during the facility's recertification survey. The findings include: On 11/12/24 at 12:07PM the surveyor observed Resident #53 to be laying in bed awake, positioned at approximately a thirty degree angle with their lunch meal on the bedside tray table which was positioned over the bed. On 11/13/24 at 11:35AM the surveyor reviewed the medical record of Resident #53 which revealed that upon admission on [DATE], they weighed 114.2 lbs. and on 11/07/2024, they weighed 103.9 lbs. indicating weight loss of the resident. Review of the physician's documentation revealed the resident had been losing weight prior to admission to the facility. On 11/15/24 at 9:31AM during review of the medical record of Resident #53 the surveyor reviewed section GG 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-20 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, interviews and medical record reviews it was determined that the facility failed to 1) label the oxygen tubing and humidifier bottle and 2) failed to follow the physician's orders to label the oxygen tubing and humidifier when changed. This was evident for one (Resident #30) of one resident reviewed for respiratory care during the recertification survey. The findings include: A nasal canula is a plastic tube that delivers oxygen into a resident's nostrils. On 11/13/24 at 12:00 PM the surveyor observed Resident #30 with oxygen 2 Liters nasal cannula in her nose. It was observed that the oxygen tubing and the humidifier bottle had not been labeled with the date and time it was placed. On 11/14/24 at 11:32 AM the surveyor observed Resident #30 with oxygen 2 Liters nasal cannula in her nose. It was observed that the oxygen tubing and the humidifier bottle had not been labeled with the date or time it was placed. On 11/14/24 at 11:35 AM Staff #24, Licensed Practical Nurse (LPN), was interviewed regarding who changes the oxygen tubing and humidifier and when is it…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-11-20 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure 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 observation, record review, and interview with facility staff, it was determined that the facility 1) failed to ensure monthly Medication Regimen Reviews were completed by the pharmacist and 2) failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1 (Resident #18) out of 5 residents reviewed for unnecessary medications during the recertification survey. The findings include: A Medication Regimen Review (MRR) is a thorough evaluation of the medication regimen (plan) of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medications. The MRR includes review of the medical record to identify, report, and resolve medication-related problems, errors, and/or other irregularities. 1) On 11/14/24 at 9:49AM, the surveyor reviewed the medical record for Resident #18 which revealed on 8/29/24, Pharmacist #17 documented in the Chronological Record of MRR in the resident's paper chart, TSH low: decrease levothyroxine. On 11/14/24 at 10:56AM the surveyor…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-11-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with facility staff, it was determined that the facility failed to ensure all employees' required immunizations and screenings were up to date, as it relates to infection prevention and control. This was evident for 2 (GNA #34 and LPN #35) of 5 employees reviewed during the recertification survey. The findings include: On 11/20/24 at 2:40PM, 5 employees' files were reviewed by the survey team. The review included TB screenings and immunizations and revealed Geriatric Nursing Assistant (GNA #34) did not have a documented TB screening on file and Licensed Practical Nurse (LPN #35) did not have a documented Tdap [tetanus, diphtheria, and pertussis (whooping cough)] immunization on file. The survey team requested documentation of these screenings and immunizations. On 11/20/24 at 3:25PM in an interview with the Licensed Nursing Home Administrator (LNHA), she stated employee health does not require Tdap for their employees, just for the pediatric unit, but she would change that…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-09-20 · tag F0838 — failed to assess facility resources and resident needs — pattern
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observations and interviews with facility staff it was determined the facility failed to complete the facility matrix accurately. This was found to be evident during the survey and has the potential to impact all residents in the facility. Findings include: The matrix is a required tool that is part of the overall facility assessment and is used in the long term care survey process to identify pertinent care categories for newly admitted residents in the last 30 days who are still residing in the facility as well as all other residents in the facility. All information entered in the matrix tool should be verified by a staff member knowledgeable about the resident population and the information must be reflective of all residents as of the day of the survey. An entrance conference was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON) on 9/15/19 at 2:40 PM. Instructions for the completing the matrix tool was provided to the NHA and DON. On 9/16/19 at 8:55 AM the DON brought the matrix to the survey team and she 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-20 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, family interview and interview with the facility staff it was determined that the facility failed to have a system in place to ensure that the Surrogate Decision Maker and resident wishes expressed under the Maryland Medical Orders for Life Sustaining Treatment (MOLST) was followed. This was true for 1 out of 22 residents (Resident #18) reviewed during the survey. The findings include: The MOLST is a form that provides orders for cardiopulmonary resuscitation (CPR), also known as full code or No CPR and other life sustaining treatments and options such as oxygen administration, blood draws, blood transfusions, x-rays, vital signs and hospitalizations. Review of the medical record for Resident #18 on [DATE] at 12:06 PM revealed a resident with multiple co-morbidities including: Alzheimer's disease, Dementia with behavior disturbances and high blood pressure. Further review revealed that the Electronic Medical Record (EMR) profile for Resident #18 indicated the resident was a full…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-20 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on resident interview, observation, record review and staff interview it was determined that after a resident to resident altercation, the facility staff failed to put adequate interventions in place to prevent further potential abuse while the investigation was in progress. The facility staff also did not provide a timely and thorough investigation to evaluate the perpetrator and determine potential mitigating factors that triggered the event and application of appropriate interventions. This was found to be true in 1 of 1 facility reportable incident reviewed during the survey. Findings include; On 09/16/19 at 8:45 am during a tour of the 3rd floor, surveyor entered the room of Resident #54 and Resident #23. The residents shared that in the evening of the previous day, Resident #18 had entered their room uninvited and attempted to get in the bed of Resident #23. When Resident #54 tried to re-direct the resident, Resident #18 used their body to immobilized Resident #54 in his/her chair, then squeezed their hands around Resident #54's neck. During the interview, Resident #23…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-09-20 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with staff it was determined that the facility failed to have a system in place to ensure that the resident and/or resident's representative were notified in writing of the resident's transfer and the rationale for the transfer. This was found to be evident for 2 out of the 2 (Resident #24 and #60) residents reviewed for hospitalization during the investigative portion of the survey. The findings include: 1. Review of the medical records for Resident #24 on 9/17/19 at 9:16 AM revealed that s/he was hospitalized on [DATE] secondary to a fall and yelling out in pain. Further review of the medical record failed to reveal any written documentation that the family or the representative were notified in writing of the reason for the resident's hospital transfer. The Director of Nursing (DON), Assistant (ADON) and the unit manager were interviewed on 9/18/19 at 3:14 PM. They verbalized that they do speak with the resident and or family upon discharge but were unaware they…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-20 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on medical record review and interview with facility staff, it was determined that the facility staff failed to transmit a discharge summary timely. This was evident during the review of 1 of 1 resident assessments (Resident #1) The findings include: Review of the medical record, including the Minimum Data Set (MDS) assessment for Resident #1 revealed a discharge from the facility on 5/31/19. Further review of the medical record revealed that according to the MDS the resident was still in the facility. Interview with Staff #8 the facility MDS Coordinator, on 9/18/19 at 2:53 PM after her investigation into the surveyor's inquiry revealed that the assessment was rejected and did not transmit as the resident's Medicare identifier numbers were entered incorrectly. Staff #8 stated that she submits assessments on Fridays and audits the reports on Mondays to ensure that the assessments were submitted however, this one must have just slipped by. The assessment was resubmitted after it was brought to staff# 8's attention.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-20 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interviews with facility staff it was determined the facility failed to develop a care plan that would ensure that a resident with cognitive impairment was kept safe and free of an alert and oriented resident who admired and was in pursuit of the cognitively impaired resident. This was found to be evident for 1 of 22 residents (Resident #49) who was reviewed for care plans during the survey. Findings include: A medical record review was conducted for Resident #49 on 9/19/19 at 8:45 AM. A nurse note dated 4/13/19 revealed the following; [Resident #29] attempted to lure [Resident #49] out of his/her room and s/he would not leave, the [Resident #29] then entered Resident #49's room and closed the door. A Geriatric Nursing Assistant (GNA) entered the resident's room to see if the resident had finished eating dinner and found both residents kissing one another. The ADON (Assistant Director of Nursing) was made aware. An interview was conducted with the ADON on 9/19/19 at 8:55 AM and she was asked what the facility had in place to ensure that the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-20 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, resident interview, record review, and staff interview it was determined that the facility staff failed to update and ensure the plan of care was reviewed and revised timely by an interdisciplinary team for residents. This was true for 1 of 3 residents (Resident #18) reviewed for care plan revision during the survey. Findings include: During an observation of the 3rd floor unit on 09/16/19 an interview was conducted at 8:45 AM, with Resident #23 and #54. Resident #54 stated that Resident #18 had entered into the room the previous evening and after attempts to redirect him/her, Resident #18 became upset and began to choke Resident #54. Resident #54 added that Resident #18's behavior was disturbing and shared his/her concerns with the nurse (Staff #14) and the Assistant Director of Nursing and requested to have the resident removed off the unit. Resident #54 said s/he was shocked to learn that Resident #18 remained on the unit and that only a stop sign on a nylon netted strip intended as a deterrent was placed at the entrance of their room. Resident #23 added…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-20 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview with facility staff, it was determined that the facility failed to: 1. have consistent documentation on the chart and the electronic medical record regarding a residents Medical Order of Life Sustaining Treatment (MOLST) forms and 2. obtain a resident consult from the pain clinic and have it on the resident's medical record. This was evident during the review of 2 of 22 residents (Resident # 24 and Resident # 40) in the investigative portion of the survey. The findings include: 1. Review of the medical record for Resident #24 on [DATE] at 9:15 AM revealed a MOLST form in the paper chart noting that on [DATE] the resident's surrogate chose for the resident to be a No Cardiopulmonary Resuscitation (CPR), Option B, Palliative and Supportive Care. Review of the resident's electronic medical record revealed another MOLST form that was scanned into the computer on admission to the facility. The MOLST form was completed on [DATE] by the resident choosing for full code status…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-09-20 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews with facility staff it was determined the facility failed to adhere to infection control practices and guidelines while administering medications. This was found to be evident for 2 of 7 residents (Resident # 176 and Resident # 74) observed during medication administration observation. Findings include: A medication observation was conducted on 9/18/19 at 8:35 AM. Staff # 1, a Certified Medicine Aide (CMA)/Geriatric Nursing Assistant (GNA) prepared medications for Resident #176 and in doing so, he crushed each medication individually and took it into the resident room. After administering the fourth medication, Staff #1 retrieved the resident cup of water and took it to the medication cart and placed it on top and refilled the cup. Staff #1 crushed the fifth medication and returned to the resident room and administered the medication with sips of water from the cup. Staff #1 did not use another cup or clean the top of the medication cart prior to sitting the cup on the top. A medication observation was conducted on 9/18/19 at 9:25 AM and Staff #1…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleSince
TIDALHEALTH, INCOrganizationDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
TRUIST COMMERCIAL EQUITY, INCOrganization5% OR GREATER MORTGAGE INTERESTsince 02/08/2021
DIRIKER, MEHMETIndividualCORPORATE DIRECTORsince 07/01/2024
FIDDLER, KATHRYNIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 03/01/2020
GARY, STEPHANIEIndividualCORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2024
ROMMEL, DAVIDIndividualCORPORATE DIRECTORsince 07/01/2024
TRUMBLE, JAMESIndividualCORPORATE DIRECTORsince 03/01/2020
WILLIAMS, ANDREAIndividualCORPORATE DIRECTORsince 07/01/2024
LEONARD, STEVENIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
SPENCE, CAMESHAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
MCCREADY FOUNDATION INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/27/1984
BUTLER, GERRODIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/01/2024
COLLINS, FRANKLINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 07/01/2014
JOHNSON, MARCIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/07/2024
KARUMBUNATHAN, VIJAYKUMARIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2020
KING, AUDREYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2024
MCGONIGLE, JAMIIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/07/2024
MILLER, LAURIEIndividualOPERATIONAL/MANAGERIAL CONTROLsince 09/07/2024
SIPE, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2020
TULL, LISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/07/2024
WARD, LORIIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2020
YANUS, SCOTTIndividualOPERATIONAL/MANAGERIAL CONTROLsince 03/01/2020

CMS files one row per role, so the 38 rows in the source record cover these 22 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.

3 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.

$7.3M
Net patient revenuemost recent cost report
-50.4%
Operating marginrevenue minus expenses
$1.7M
Related-party expense16% of expenses
Who pays — share of resident-days
Medicaid 70%Medicare 10%Other / private 20%

About 70% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $1.7M paid to related parties — landlords or management companies under common ownership — equal to about 16% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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

$447per resident / day
operating cost
$13,600per month
≈ monthly operating cost
$298per day
avg. revenue, all payers

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

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Maryland Medicaid page.

Typical monthly cost in Maryland
$12,927/mo
Nursing home (semi-private)
$14,448/mo
Nursing home (private)
$7,173/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215058. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-06, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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