Devlin Manor Nursing And Rehabilitation Center
10301 North East Christie Road, Cumberland, MD 21502 · For profit - Corporation · 124 certified beds · (301) 724-1400 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Mar 2026
- 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 (25) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $12,735 in federal fines (most recent 2026-03-20)
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 | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 3 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 4 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 4 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 | 29.4% | 20.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 7.8% | 5.4% | 5.4% | worse |
| 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 | 2.2% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 29.1% | 22.8% | 6.5% | worse 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 | 1.3% | 2.4% | 3.3% | better |
| Long-stay residents whose ability to walk worsened | 24.5% | 22.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 32.2% | 16.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 92.2% | 96.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 7.2% | 5.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 16.8% | 25.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 30.3% | 13.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.6% | 80.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 24.1% | 21.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 9.5% | 9.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.55 | 1.33 | 1.67 | typical |
| Long-stay outpatient ER visits per 1,000 resident days | 1.46 | 1.20 | 1.80 | better |
‡ 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.
49.6% 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 167 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 58.4% 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 77 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 0.33 therapist hours per resident per day in 2026Q1 — more than 56% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 4% 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
| 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 | 49.6%CMS range 42.5–58.1 | 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 | 13.7%CMS range 10.5–18.3 | 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 | 58.4% | 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 | 59.7% | 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 | 48.0% | 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 | 99.0% | 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 | 95.5% | 100.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.2% | 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 | 1.1% | 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 | 2.1% | 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 | 7.0%CMS range 4.5–10.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.95 | 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 124 beds and averages 93.9 residents a day — about 76% occupied, or roughly 30 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.18 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.56 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 2.59 hrs/resident/day on weekends vs 3.42 on weekdays — 24% thinner on weekends — a notable drop. RN hours go from 0.56 to 0.55 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 42% 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
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.
25 citations, most serious first. The 11 most serious are shown; the remaining 14 are one tap away and print in full.
- Actual harm · G2026-03-20 · tag F0711 — isolatedEnsure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility staff failed to monitor a resident with abnormal lab findings. The failure to do so, resulted in harm to the resident since the resident had to be hospitalized for treatment. This was evident for 1 (#6) of 2 residents reviewed for quality of care. The findings include:Cirrhosis of the liver is a condition in which the liver becomes scarred and unable to work properly. Ascites is a complication in which the liver does not produce protein in the blood causing fluid to build up in the abdominal cavity and if left untreated it can cause the resident to have trouble breathing. Esophageal varices is a complication that is caused by increased pressure in the portal (liver) vein that results in weak blood vessels in the esophagus. These weak blood vessels bleed easily and are the cause of 1/3rd of the deaths from cirrhosis. Lastly, with endstage liver disease, the liver cannot rid the body of waste and allows ammonia to build up in the blood. The high ammonia levels cause hepatic encephalopathy as evidenced by changes…
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 before2026-06-30 · 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 record review and interview it was determined the facility staff failed to report an allegation of abuse to the local law enforcement authorities. This was evident for 1 (#3) of 2 residents reviewed for abuse.The findings include:Investigation documentation and facility reported incident (FRI) #3022768 was reviewed on 6/26/26 at 12:30 PM. The review revealed that on 5/22/26 at approximately 9:00 PM, Resident #3 reported to Licensed Practical Nurse (LPN) #3 that s/he experienced pain while receiving evening care from Geriatric Nursing Assistant (GNA) #4; and the GNA failed to stop when Resident #3 repeatedly told her to stop because she was causing pain. GNA notified the nurse. The resident spoke to a family member immediately after the encounter. The family member telephoned the facility and spoke to the nurse.The resident was assessed by LPN #3 at that time, no injuries were found, and the report of an allegation of abuse was submitted to the state agency. GNA #4 was suspended pending the outcome of the facility's investigation.The facility's self-report indicated 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.
- Potential for harm · E2026-03-27 · tag F0578 — failed to honor advance directives / code status — patternHonor 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 record review and staff interviews, it was determined that facility staff failed to 1) ensure advance directives and decision-making authority were established and maintained for a resident who lacks decision making capacity and 2) document that residents were informed of their right to formulate Advance Directives upon admission. This deficient practice was evident for 4 (Resident #4, #1, #10 and #11) of 4 residents reviewed for Advance Directives during the annual survey. The findings include: 1) On 03/25/26 at 9:40 AM, a review of Resident #4's medical record indicated the resident lacked decision making capacity at the time of admission in March 2024. The resident's medical record failed to show evidence the facility obtained documentation of an authorized decision-maker, including advance directive for the resident. During an interview with the Director of Social Services (DSS) #14 on 03/25/26 at 10:15 AM, she reported that the resident's family member had been making decisions since 2024; however, no legal documentation was present to support the family member'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 · E2026-03-27 · tag F0880 — failed to prevent and control infections — patternProvide 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 and interview, the facility failed to process and store linens in a manner to maintain infection prevention. This was evident during 1 of 1 observation of the laundry room during an annual survey.The findings include:On 03/24/26 at 9:02 AM, an observation of the hallway by the clean and dirty laundry rooms revealed two uncovered clothing racks which appeared to be full of resident linen.At the same time, further observation of the hallway revealed a room which had a singular washer and dryer next to one another. Further observation of the room revealed an uncovered clothing rack labeled, unlabeled clothing, and a medium sized basket on the floor of various rags/cloths.On 03/24/26 at 9:03 AM, an interview with Housekeeping Aide (Staff #16) revealed that only resident linen was washed, dried, and sorted in the room where there was a singular washer and dryer. She further indicated they have separate clean and dirty laundry rooms for bed linen, towels, and other items other than resident clothing. During the same interview, the surveyor asked Staff #16 what 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 · D2026-03-27 · tag F0551 — isolatedGive the resident's representative the ability to exercise the resident's rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that facility staff failed to make sure a legal decision maker was in place for a resident in a timely manner. This deficient practice was evident for one resident (Resident #4) reviewed for decision making capacity during the annual survey.The findings include:On 03/25/26 at 9:40 AM, a review of Resident #4's medical record revealed an admission date of 03/06/2024, with multiple diagnoses, including dementia. Further review indicated that no advance directives were documented for the resident. On 05/31/2024, the attending physician, and on 06/03/24 the nurse practitioner, certified that Resident #4 lacked decision making capacity. The medical records failed to show evidence of a court appointed legal healthcare decision maker.On 03/25/26 at 10:15 AM, during an interview, the Director of Social [NAME] (DSS) #14 stated that when a resident is admitted without decision-making capacity, the facility contacts the resident's family and advises them to seek…
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 · D2026-03-27 · 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
Based on resident record review and staff interview, it was determined that the facility failed to conduct a comprehensive Minimum Data Set (MDS) assessment within 14 days of a significant change. This was evident for 1 (Resident #52) of 3 residents reviewed during the annual re-certification survey.The findings included:On 03/23/26 at 10:28 AM, during the initial observation, Resident #52 was observed lying in bed on her back and her left hand was contracted.On 3/25/26 at 7:38 AM, Resident #52's medical records were reviewed and revealed that Physical Therapy (PT) assessed contractures of her right and left ankle upon their admission assessment on 3/1/23.Occupational Therapy (OT) notes revealed Resident #52 had contracture of muscle in their left hand on 4/26/24.The MDS assessments were then reviewed and revealed that in section GG functional limitation in range of motion on 6/7/2024, 9/5/2024, and 12/6/24, the upper extremities (shoulder, elbow, wrist, and hand) were documented as no impairment, even though Resident #52 was being treated by OT for left hand contraction since…
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 · D2026-03-27 · tag F0655 — isolatedCreate 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 interviews with facility staff, it was determined that the facility staff failed to develop a 48-hour baseline care plan upon admission. This was evident for 1 (Resident # 106) of 20 residents reviewed for care plans during the annual re-certification survey.The findings include: On 03/24/26 at 1:53 PM Resident #106 medical records were reviewed and revealed that Resident #106 was admitted to the facility on [DATE]. The baseline care plan could not be found in the Matrix, the facilities electronic health records (EHR).On 03/24/26 at 2:43 PM Staff #5, the Regional Clinical Director of Nursing (CDON) was asked to provide a copy of Resident #106's 48-hour baseline care plan.On 03/24/26 at 2:58 PM Staff #2, the Director of Nursing (DON) and Staff #5 CDON were interviewed and asked if they had documentation that Resident #106's 48-hour base line care plan was completed. The DON stated that they did not do the 48-hour care plan for Resident #106. Both the DON and the CDON…
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 · D2026-03-27 · 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 — the official record, unedited, may be distressing
Based on observations, staff interviews, and record review, it was determined that the facility staff failed to revise the comprehensive care plan to reflect the resident's need for oxygen therapy. This deficient practice was evident for one (Resident #19) resident reviewed for care plans during the annual survey.The findings include:On 03/23/2026 and 03/24/2026, the surveyor observed Resident #19 in bed receiving oxygen at 2 liters via nasal cannula.A review of the resident's comprehensive care plan failed to include the use of oxygen therapy, monitoring, or interventions related to respiratory needs.On 03/24/2026, during an interview, the Director of Nursing (DON) acknowledged that the care plan should have been updated to reflect the resident's oxygen use following the hospitalization in October 2025 and November 2025.A review of the hospital discharge summaries dated October 2025 and November 2025 confirmed ongoing oxygen therapy needs; however, the care plan was not updated to reflect these changes in condition.
- Potential for harm · D2026-03-27 · tag F0658 — failed to meet professional standards of care — isolatedEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, staff interviews, and record review, it was determined that the facility failed to ensure physician orders were obtained and implemented for oxygen therapy. This deficient practice was evident for one resident (Resident #19) reviewed for professional standard of practice during the annual survey.The findings include:On 03/23/2026 and 03/24/2026, the surveyor observed Resident #19 in bed receiving oxygen at 2 liters via nasal cannula.On 03/24/2026, during an interview, the Registered Nurse (RN) #12 confirmed the resident was receiving oxygen. Both the surveyor and RN #12 reviewed the resident's medical record which failed to reveal an order for oxygen. The RN acknowledged the order was missing and stated the resident should have an oxygen order.A review of the resident's hospital discharge documents dated October 2025 indicated the resident was to be weaned to 1 liter of oxygen, and hospital discharge documents dated November 2025, indicated a history of hypoxia (low oxygen) requiring 3 liters of oxygen via nasal cannula.On 03/24/2026, the Director of Nursing…
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 · D2026-03-27 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations, record review and interviews, it was determined that the facility failed to ensure that a dependent resident's grooming needs were met. This was evident in 1 (Resident# 10) of 1 resident reviewed for Activities of Daily Living (ADL).The findings include:On 03/23/26 at 11:36 AM the surveyor observed Resident #10 sitting at the side of his/her bed, with a disheveled appearance and facial hair about a quarter of an inch long.On 0/23/26 a review Resident #10's most recent MDS ARD 02/11/26 revealed a Brief Interview Mental (BIMS) score of 6 indicating severe cognitive impairment. A further review of the clinical record and care plans did not find evidence that the resident refused care, including shaving and grooming.On 03/23/26 at 2:28 PM in an interview GNA #19 stated that she was not assigned to the resident at the time of the interview, but she had a good relationship with the resident. She indicated that whenever she provided care the resident did not refuse grooming.On 03/24/26 at 1:10 PM the surveyor again observed the resident with unshaven facial hair…
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 · D2026-03-27 · tag F0685 — isolatedAssist a resident in gaining access to vision and hearing services.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and interviews, it was determined that facility staff failed to ensure effective communication by not addressing hearing impairment for a resident identified with hearing loss. This deficient practice was evident for one (Resident #82) resident of two residents reviewed for vision and hearing during the annual survey.The findings include:On 03/24/26 at 10:08 AM, during an interview with Resident #82, the resident reported difficulty hearing and asked the surveyor to stand on the left side of the bed since hearing is better with the left ear. The resident also reported they did not have hearing aids.Review of the care plan dated 02/06/2025 identified hearing loss and included interventions such as facing the resident and speaking clearly. A review of the minimum data set (MDS) dated [DATE] indicated minimal hearing difficulty. The most recent MDS dated [DATE] indicated a decline in hearing to moderate hearing difficulty. Further review of the medical record failed to show…
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 14 citations
- Potential for harm · D2026-03-20 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility failed to ensure their residents were free from abuse. This was evident for 1 of 2 residents reviewed for abuse.The facility implemented effective and thorough corrective measures following this incident prior to the start of this survey. The facilities plan and action were verified during this survey, therefore this deficiency was found to be past noncompliance with a compliance date of 1/23/26.The findings include:MDS (Minimum Data Set) - is 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. A medical record review on 3/19/26 at 9:50 AM for Resident #4 (R4) revealed a Minimum Data Set (MDS) that documented the resident had no behaviors, severe cognitive impairment, unclear speech, and s/he understood what was being said sometimes. Furthermore, it was documented that the resident relied on staff to provide most ADLs (activities…
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 before2026-03-20 · 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 record review and interview, it was determined that staff failed to recognize and report allegations of abuse to the State Agency within the required timeframe. This was evident for 1 of 4 facility reported incidents reviewed.The findings include:On 3/19/26 at 10:01 AM a review of the facility's investigation file for the facility reported incident #2726923 revealed on the initial report form it was indicated that the Director of Nursing (DON) became aware of an allegation of abuse on 1/21/26 at 9:32 AM. However, further review of the investigation file revealed that GNA #3 verbally abused Resident #6 on 1/20/26 during the evening shift. It was witnessed by facility staff who failed to report the abuse. The email confirmation read the report was sent to the State Agency (SA) on 1/21/26 at 12:42 PM. An interview with Certified Medicine Aide (CMA) #5 on 3/19/26 at 3:15 PM revealed she was present when the abuse occurred and confirmed it was on 1/20/26 between 8:00 PM - 8:30 PM. The concerns were reviewed with the DON on 3/19/26 at 1:34 PM. She reported that she thought 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 · D2026-03-20 · 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 that facility staff failed to that a staff member who was observed abusing a resident, no longer had access to vulnerable residents to ensure there was no further abuse. This was evident for 1 (#4) of 1 resident review for abuse.The findings include:A medical record review for Resident #6 (R6) on 3/19/26 at 9:50 AM revealed a minimum data set (MDS) with an assessment reference date of 12/18/25 that read the resident had a diagnosis of dementia and was severely cognitively impaired.During a review of the facility's investigation file for the facility reported incident #2726923 on 3/19/26 at 10:01 AM revealed that GNA #3 abuse Resident #6 (R6) on 1/20/26 during the evening shift. While GNA #3 and GNA #4 was putting the resident back to bed GNA #3 stated to the resident, Do not fucking hit me. However, facility staff failed to recognize the abuse, and it was not reported to the Director of Nursing (DON) until 1/21/26 at 9:32 AM. On 3/20/26 at 9:30 AM staff assignment sheets for 1/20/26 and 1/21/26 were reviewed. Based on these…
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 before2026-03-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that facility staff failed to ensure that a resident had the medications they needed upon admission and throughout their stay. This was evident for 1 (#6) of 2 residents reviewed for quality of care concerns.The findings include:A medical record review on 3/17/26 at 9:36 AM for Resident #6 (R6) revealed the discharge summary from the hospital for 11/25. According to the record the resident had cancer of the pancreas (an organ that secretes enzymes to assist with digestion and absorption of nutrients) and had a Whipple procedure (a procedure in which the head of the pancreas, the first part of the small intestines, the gallbladder and the bile duct is removed) to treat the cancer. Further review of the discharge summary revealed the resident was on Creon, which was a medication with three pancreatic enzymes to assist with digestion and absorption of nutrients and was usually taken with every meal. A review of the resident's orders revealed the resident was ordered Creon 24,000-76,000-120,000 unit; administer 1 capsule by mouth 3…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2026-03-20 · tag F0865 — failed to run a quality-improvement (QAPI) program — isolatedHave a plan that describes the process for conducting QAPI and QAA activities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview, it was determined that the facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) program. This was evident during the review of the QAPI program for the revisit survey.The findings include:A QAPI plan is the written plan containing the process that will guide the nursing home's efforts in assuring care and services are maintained at acceptable levels of performance and continually improved.On 5/14/26 at 1:09 PM a review of the facility's QAPI program information provided by the Quality Assurance (QA) coordinator failed to reveal the facility's QAPI plan. An interview with the Director of Nursing (DON) and QA Coordinator on 5/14/26 at 1:20 PM revealed that they were unaware of the regulatory requirements for the development of a QAPI plan and unsure if the facility had developed one. The DON reported she would need to contact their corporate consultants to determine if they had a QAPI plan. The QA coordinator reported that she was responsible for overseeing the program and conducting the QAA [Quality…
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 · D2026-03-20 · tag F0867 — failed to act on quality-improvement findings — isolatedSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
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, it was determined that the facility failed to ensure they had an effective Quality Assurance and Performance Improvement Program to include the development and implementation of polices and procedures for the program. This was evident during the revisit survey.The findings include:During a complaint survey on 3/20/26, the facility was determined to be out of compliance with CMS regulation 483.30(b) physician visits and it resulted in harm to a resident.A medical record review for Resident #1 on 5/13/26 at 12:18 PM revealed a hospital Discharge summary dated [DATE] documenting the resident had multiple duodenal (first section of the small bowels) ulcers. The resident was listed as NPO (nothing by mouth) for their diet and was receiving TPN (total parenteral nutrition - nutrition through an intravenous line) and the resident was to receive medications orally. The list of discharge medications included but were not limited to a proton pump inhibiter (decreases gastric juices…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-09-12 · tag F0684 — failed to provide proper treatment and quality of care — patternProvide 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 interview, record review, facility document review, and facility policy review, the facility failed to timely assess and implement interventions after a change of condition for 2 (Resident #2 and Resident #4) of 3 residents reviewed for change of condition. The failure resulted in a delay of assessment and treatment for Resident #2 and Resident #4. Findings included: A facility policy titled, Physician and Other Communication/Change in Condition, revised 05/05/2023, specified To improve communication between physicians and nursing staff to promote optimal patient/resident care, provide nursing staff with guidelines for making decisions regarding appropriate and timely notification of medical staff regarding changes in a patient's/resident's condition, and provide guidance for the notification of patients/residents and their responsible party regarding changes in condition. The policy also indicated, The nurse will document all assessments and changes in the patient's/resident's condition in the medical record. Changes and new approaches will be reflected in 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 · Dcited before2025-09-12 · 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 interviews, record reviews, and facility policy review, it was determined the facility failed to report an allegation of misappropriation of property timely to the state survey agency for 1 (Resident #6) of 5 facility-reported incidents for allegations of abuse, neglect, and misappropriation of property. Specifically, Resident #6 alleged to have $230 missing in January 2025, and the facility did not report the allegation to the state agency until April 2025.Findings included:The facility's undated policy, titled, Abuse, Neglect, Exploitation, or Mistreatment, indicated, The facility's Leadership prohibits neglect, mental, physical and/or verbal abuse, use of a physical and/or chemical restraint not required to treat a medical condition, involuntary seclusion, corporal punishment, and misappropriation of a patient's/resident's property and/or funds and ensures that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, and are reported immediately.Resident #6's Face Sheet…
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 before2025-01-17 · 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 interview, record review, and policy review, the facility failed to develop a care plan related to anticoagulant medication for one (Resident (R)28 residents in the sample of 28 residents. The deficient practice had the potential to cause an adverse reactions from receiving an anticoagulant medication. Findings include: 1. Review of R28's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R28 was admitted to the facility on [DATE] with diagnoses that included unspecified disorders of the brain-cerebral ventriculomegaly, and paroxysmal atrial fibrillation. Review of R28's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/22/24 located in the EMR under the MDS tab revealed a Brief Interview for Mental Status (BIMS) score of 09 out of 15 which indicated R28 was moderately impaired for decision-making. This MDS assessment further indicated R28 receives an anticoagulant. Review of R28's Physician Orders dated 10/16/23 in the EMR under 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 · F2023-09-20 · tag F0850 — failed to provide social-work services — widespreadHire a qualified full-time social worker in a facility with more than 120 beds.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility staff roster review and staff interview, it was determined that the facility has a bed capacity of 127 and did not employ a qualified social worker from December 2021 until July 2022 on a full-time basis. This deficient practice was found during an complaint survey and has the potential to affect all residents. After review of human resources records and staff interview it was determined the facility currently has employed a qualified social worker so this deficiency will be cited as past non-compliance with a correction date of July 12, 2022. The findings include: Interview with the Director of Nursing (DON) and the Administrator on 9/20/23 at 1:00 PM revealed the facility failed to employ a qualified Social Worker from December 2021 to July 2022. The Administrator stated when Staff #2 left the facility in December 2021 for another position, the facility had a difficult time finding another qualified social worker. Recruitment efforts were unsuccessful until July 2022 when Staff #32 was hired on July 12, 2022. The surveyor asked the DON and the Administrator about…
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 before2023-09-20 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, it was determined the facility staff failed to provide Resident (#20 and #27) with care which promoted the highest practicable well-being. This was evident in 2 of 48 residents selected for review during a complaint survey. The findings include: 1. Based on medical record review of Resident #20's records and review of complaint MD00178254 it was determined the facility staff failed to follow a physician order written on 05/09/2023 for the bed to be in low position with fall mats when Resident #20 was in bed. On 9/18/23 at 9:30 AM, an observation of Resident #20 revealed the resident in bed with no fall mats. The Unit 3rd floor Manager (#11) was in the hall at that time and confirmed that the resident did not have fall mats as ordered. Interview with the Director of Nursing on 9/18/23 at 11 AM confirmed the facility staff failed to follow the physician orders for Resident's #20 fall mats. 2. Review of Resident #27's medical record on 9/20/22 at 9:00 AM in connection…
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 before2023-09-20 · tag F0755 — failed to provide safe pharmacy services — isolatedProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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 failed to provide adequate management of a resident's pain medication pharmacy order (Resident #27) resulting in the resident being denied scheduled pain medication when the pharmacy failed to deliver the medication to the facility. This was evident for 1 of 48 residents reviewed. The findings include: Review of Resident #27's medical record on 9/20/22 at 9:00am in connection with review of complaint MD00182385 revealed the resident was admitted to the facility on [DATE] at 8:28pm. Further review of the resident's medical records on 9/20/22 at 9:30am revealed the physician ordered oxycodone 10mg 4 times a day (8am, 12pm, 4pm, and 8pm) on 8/11/23 at 5:50pm. Review of the resident's medication administration records for August 2022 revealed facility nursing staff failed to administered oxycodone 10mg when Resident #27 was admitted and for the medication times 8am, 12pm, and 4pm on 8/12/22. Resident #27 was transferred from 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 · D2019-11-08 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation, the facility staff failed to maintain dignity for Resident #50 while assisting the Resident with lunch. This was evident for 1 out of all Residents observed during the lunch dining service during the survey process The findings include: On 11/08/19 around 11:34 AM, while observing Resident #50's positioning for meals, it was noted that staff # 5 was assisting the resident with the meal. Writer observed Staff # 5 feeding the resident from a standing position, leaning toward the resident. Writer informed Staff # 4 who acknowledged and witnessed the episode. Staff should not be standing over residents while assisting them to eat. Residents have a right to be treated with dignity and as much independence as possible when dining.
- Potential for harm · Dcited before2019-11-08 · 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 records and staff interviews, it was determined that the facility staff failed to develop a Care Plan for Resident #89, related to the Resident's combativeness. This was evident for 1 out of 35 residents investigated during the survey process. The findings include: On 11/04/19 around 03:17 PM, while interviewing Resident 89's significant other for a family interview, the spouse expressed concerns about bruises on the resident's left hand. Further review of the record revealed that. on 10/17/19, GNA #6 stated that while providing care, the resident was very combative. Per the GNA, the resident was due for a complete bed change, clothes and brief. The GNA was providing care and had to yell for help due to the resident's behavior . Reportedly, the resident was hitting the GNA, grabbing the brief and shirt, and would not roll over. The GNA stated that the resident was grabbing, twisting and squeezing the GNA's arms and wrist between their legs while the GNA was trying to pull up the brief. At no time did the GNA see the resident actually hurt their self, but with all…
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
$12,735 in federal fines across 1 penalty.
- $12,735 — penalty dated 2026-03-20
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Part of a chain
This home belongs to FUNDAMENTAL HEALTHCARE — 66 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 | 3 of 5 | 2.4 | +0.6 vs chain |
| Health inspection | 3 of 5 | 2.5 | +0.5 vs chain |
| Staffing | 3 of 5 | 2.2 | +0.8 vs chain |
| Quality measures | 3 of 5 | 3.4 | -0.4 vs chain |
The other 65 homes this chain runs (chain average 2.4★, per CMS)
Showing 40 of 65; 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 | Share | Since |
|---|---|---|---|---|
| MARYLAND LONG TERM CARE LLC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/18/2016 |
| FORMAN, MURRAY | Individual | 5% OR GREATER DIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED | since 03/28/2006 |
| ADAMS, CHRISTOPHER | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 01/02/2017 |
CMS files one row per role, so the 4 rows in the source record cover these 3 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner 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.
About 73% 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 $451K paid to related parties (affiliated landlords or management companies) in its most recent cost report. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MD
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Maryland Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215244. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-27, 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.