Wilson Health Care Center
301 Russell Avenue, Gaithersburg, MD 20877 · Non profit - Corporation · 285 certified beds · (301) 216-4004 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (14% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has an abuse, neglect, or exploitation citation (F0600), cited Apr 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 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 held steady at 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 20.2% | 20.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 5.4% | 5.4% | 5.4% | typical |
| Long-stay residents with a catheter left in their bladder | 0.7% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.3% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 3.9% | 22.8% | 6.5% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.3% | 2.4% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 27.3% | 22.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 10.0% | 16.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 98.5% | 96.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 4.5% | 5.9% | 4.7% | typical |
| Long-stay residents with worsening bladder/bowel control | 22.4% | 25.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 13.1% | 13.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 1.1% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 97.0% | 80.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.2% | 21.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 8.0% | 9.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.14 | 1.33 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.60 | 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.
61.7% 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 714 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.1% 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 271 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 0.43 therapist hours per resident per day in 2026Q1 — more than 73% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 61.7%CMS range 59.0–65.0 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.1%CMS range 8.1–11.9 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.1% | 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 | 59.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 62.4% | 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 | 99.4% | 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 | 100.0% | 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 | 98.7% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 2.5% | 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 | 6.5%CMS range 4.3–8.9 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.97 | 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 285 beds and averages 163.3 residents a day — about 57% occupied, or roughly 122 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.12 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.06 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.13 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 3.66 hrs/resident/day on weekends vs 4.31 on weekdays — 15% thinner on weekends. RN hours go from 1.16 to 0.80 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 14% is below 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 fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.
- Potential for harm · Dcited before2026-05-01 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, staff interview, and facility policy review, it was determined that the facility failed to ensure that a resident's right to formulate an advance directive and to have a properly identified and authorized representative make healthcare decisions was maintained for 1 (Resident #15) of 4 residents reviewed for advanced directives during the annual survey. Findings include: On 04/28/2026 at 9:32 AM, an initial review of Resident #15's medical record revealed the resident had two incapacity certifications dated 6/28/24 and 7/10/24. There were 2 individuals noted to be making decisions for the resident, one was a niece of the resident, and the other was a friend who had Financial Power of Attorney. The medical record failed to contain documentation identifying a legally authorized representative or copies of a financial power of attorney (POA) documentation. On 04/29/2026 at 12:50 PM, further review of the Resident's medical records revealed multiple consent forms, including vaccine consents dated 8/7/24 and 7/7/25, that identified an individual as POA; however,…
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 · D2026-05-01 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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, facility investigative materials, and staff interview, the facility failed to ensure the confidentiality and protection of a resident's medical record from unauthorized disclosure. This deficient practice was identified for 1 of 2 residents (Resident #138) reviewed as part of facility-reported incident investigations during the recertification/complaint survey.The facility implemented corrective actions prior to the start of the survey. Surveyor verification of the facility's corrective measures determined that the deficient practice had been corrected. Therefore, this deficiency is cited as past noncompliance with a compliance date of 07/03/2025. The findings include:HIPAA stands for the Health Insurance Portability and Accountability Act of 1996, a U.S. federal law designed to protect sensitive patient health information from being disclosed without consent. It establishes national standards for privacy, security, and electronic transactions of, or related to, Protected Health…
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 · D2026-05-01 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interview, record review, and staff interview, the facility failed to ensure that a resident received necessary services and equipment to maintain or enhance independence in activities of daily living, specifically related to bed mobility. This deficient practice was identified for 1 (Resident #65) of 2 residents reviewed for accommodation of needs. The findings include: On 4/27/2026 at 11:31 AM, an interview was conducted with Resident #65, who reported that the facility removed the bed rails from their bed due to concerns regarding entrapment risk. The resident expressed that without the bed rails, they experienced decreased independence with repositioning in bed and voiced fear of rolling out of bed during care. On 4/28/2026 at 12:36 PM, a review of physician orders revealed an order dated 9/27/2024 for Bilateral upper bedrails for bed mobility and promotion of independence per resident request, which was discontinued on 3/31/2026. On 4/28/2026 at 12:38 PM, Resident #65's Health Status Note from 3/31/2026 was reviewed. The note stated the resident was notified…
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 · D2026-05-01 · 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 interviews and record reviews, it was determined that the facility failed to provide dependent residents with showers. This was evident for 1 (Resident #18) out of 11 reviewed for activities of daily living during the recertification survey.The findings include:On 04/27/2026 at 1:58 PM, an interview with Resident #18's representative was conducted. They reported that Resident #18 preferred showers over bed baths, but the facility had not showered the resident in a long time.On 04/29/2026 at 11:54 AM, a review of Resident #18's medical record was conducted. The review revealed that the resident was scheduled to be showered every Mondays and Thursdays 3pm-11pm shift.Review of the Resident #18's preference evaluation indicated that the resident preferred showers in the morning.Review of the care plan and progress notes, failed to indicate that the resident refused showers.On 04/29/2026 at 1:05 PM, further review of the records revealed that Staff #9 had showered Resident #18 on 4/6/26, 4/10/26, 4/13/26, 4/16/26 and 4/20/26. No showers were documented for 4/2/26, 4/3/26,…
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 before2026-05-01 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews, it was determined that the facility failed to ensure that residents had call bells within reach. This was evident for 2 residents (Resident #122 and #181) out of 10 randomly selected residents observed on the unit during the recertification survey. The findings include:On 04/29/2026 at 3:05 PM, Surveyor observed Resident #122's call bell on the floor. When asked where the call bell was, Resident #122 looked around their bed and reported they didn't see it.On 04/29/2026 at 3:07 PM, an interview was conducted with Staff #14. Staff #14 stated that it is the facility staff's responsibility to ensure that resident call bells are within reach at all times. During an observation of the resident's room with Staff #14, she indicated that the call bell should have been clipped to the resident's bed to ensure accessibility. On 04/29/2026 at 3:15 PM, Surveyor observed Resident #181's call bell on the floor. On 04/29/2026 at 3:20 PM, an interview was conducted with Staff #15. Staff #15 stated that the resident was in therapy and reported that she was unsure…
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 before2026-05-01 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, it was determined that the facility failed to maintain the accuracy of the content of R14's EMR (electronic medical record). This was evident for three residents (R14, R179, and R180) as R14's EMR contained medical documents for R179 and R180. The findings include:A review of R14's EMR was performed on 4/28/26 at 11:30 AM. During the review, it was found that medical documents for two other residents had been added to R14's EMR. The surveyor note that on 4/22/26 at 1:45 AM, RN33 uploaded into R14's EMR under the Documents tab, a hospital discharge summary for R179 and the baseline care plan for R180.During an interview on 4/30/26 at 8:35 AM, DON2 stated, Anyone can upload documents into the resident's EMR under the Documents tab but usually the clerks do it. DON2 also confirmed that RN33 was a staff nurse at the facility. During an interview on 5/1/26 at 10:54 AM, NHA1 confirmed that there were two wrong documents uploaded into R14's EMR.
- Potential for harm · Ecited before2025-04-10 · tag F0842 — failed to keep accurate, complete medical records — patternSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interviews with facility staff, it was determined the facility failed to ensure that: 1) staff accurately documented if a resident exhibited side effects while receiving anti anxiety medications; 2) staff accurately documented a resident's Treatment Administration Record; 3) staff accurately documented side effects of antipsychotic and anticoagulant medications; 4) antipsychotic medication monitoring on the treatment administration record (TAR) was documented to reflect resident status; 5) resident medical records accurately reflect a resident's status; and 6) resident's medical records were complete and accurately reflects the residents advance directive status. This was found to be evident for 5 (Resident #7, # 27, #55, #91, and #367) of 6 residents reviewed for unnecessary medications, 1 (Resident #49) of 3 residents reviewed for hospitalization, and 1 (Resident #121) of 4 residents reviewed for advance directives. The findings include: 1) Resident #7's medical record was reviewed on 4/10/25 at 10:58 AM and it revealed the resident had 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 before2025-04-10 · tag F0578 — failed to honor advance directives / code status — isolatedHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, it was determined that facility staff failed to ensure that a resident's Advance Directive (AD) was completed. This deficient practice was evident for 1 (#121) of 3 residents reviewed for AD during the survey. The findings include: Advance Directive is a written instruction, such as a living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. On 04/08/25 at 10:43 AM, a review of Resident #121's AD in the paper chart revealed several oversights. There was no indication of when the designated health agent's power would become effective--immediately or whenever the resident was unable to make informed healthcare decisions. The resident did sign the AD, but the form was not dated, and the signature and date for two witnesses were left blank. Additionally, part one of the organ donation section was incomplete, and the witness signature and dates were left blank. On 04/09/25 at…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-04-10 · 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 with staff, it was determined that the facility failed to ensure a resident was free from misappropriation of resident property. This was evident for 1 facility reported incident (MD00214164) out of 5 facility reported incidents reviewed during the survey. The findings include: On 4/10/2025 at 7:30AM, a review of Resident #19's investigative file for the facility reported incident (FRI) MD00214164 revealed that on 1/24/2025 at 8:10AM, the resident notified the Nursing Home Administrator (NHA) that his/her credit card was missing, and that his/her credit card had been used four times on the evening of 1/23/2025 between 6:46PM and 8:41PM. An additional review of the investigative file revealed that after a thorough investigation, the facility was able to verify the allegation of misappropriation of resident property due to theft and use of the resident's credit card at various stores. On 4/10/2025 at approximately 1:20PM, the Surveyor conducted an interview with the NHA which confirmed the allegation of misappropriation of Resident #19's credit…
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 · D2025-04-10 · tag F0622 — isolatedNot transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to include the resident comprehensive care plan goals with the required documentation during a transfer. This was evident for 1 (Resident #55) of 3 residents reviewed for hospitalization. The findings include: On 04/08/25 at 11:05 AM, review of Resident #55's medical record revealed he/she was hospitalized on [DATE]. On 04/09/25 at 10:24 AM, an interview with Charge Nurse/ Licensed Practical Nurse (Staff #20) revealed that comprehensive care plan goals were not sent with a resident upon a transfer. On 04/09/25 at 11:10 AM, an interview with Registered Nurse (Staff #21) revealed that comprehensive care plan goals were not sent with a resident upon a transfer. On 04/10/25 at 06:53 AM, the surveyor reviewed the concern with the Director of Nursing.
Show the remaining 18 citations
- Potential for harm · D2025-04-10 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, it was determined that facility staff failed to ensure that the resident and resident representative were notified in writing of a transfer and reason for transfer to the hospital. This was evident for 2 (Residents #55 and #54) of 3 residents reviewed for hospitalization. The findings include: 1. On 04/08/25 at 11:05 AM, review of Resident #55's medical record revealed he/she was hospitalized on [DATE]. On 04/10/25 at 06:53 AM, an interview with the Director of Nursing revealed that the resident and responsible representatives were verbally notified, but that there was not a written notice with reason for transfer provided. The surveyor reviewed the concern. 2. On 4/8 2025 at 12:40PM, a review of Resident #54's electronic medical record revealed that the resident was transferred to the hospital on 1/28/2025 after sustaining a fall. On 4/10/2025 at 10:45AM, an additional review of Resident #54's medical record failed to reveal documentation to indicate the resident and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-04-10 · tag F0657 — failed to keep the care plan current — isolatedDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record reviews and interviews, it was determined that facility staff failed to update a resident's care plan to address falls involving equipment. This deficient practice was evident for 1 (#121) of resident review for care plan revision during the survey. The findings include: During an interview with Resident #121 on 04/08/25 at 10:15 AM, they reported that the break lever on their wheelchair was broken. As a result of the broken lever, they had multiple falls while attempting to stand up or sit down using the wheelchair. Review of communication form and progress note revealed that Resident #121 had a fall on 10/07/24, 12/12/24, 12/27/24, 03/19/25, 04/09/25. On 04/09/25 at 1:05 PM, a review of the residents' post fall evaluation progress note dated 10/07/24 indicates that Resident #121 had an unwitnessed fall in their room while attempting to get into bed, and the wheelchair was involved in the fall. A review of physical therapy treatment note dated 12/30/24 revealed that physical therapy was informed of a fall the resident had in the bathroom. The resident reported 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.
- Potential for harm · Dcited before2025-04-10 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews, observations, and record reviews, it was determined that facility staff failed to ensure that a resident's wheelchair was safe for use. This deficient practice was evident for 1 (#121) resident review safety hazards during the survey. The findings include: During an interview with Resident #121 on 04/08/25 at 10:15 AM, they reported that the break lever on their wheelchair was broken. As a result of the broken break lever, they had multiple falls while attempting to stand up or sit down using the wheelchair. Review of communication form and progress note revealed that Resident #121 had a fall on 10/07/24, 12/12/24, 12/27/24, 03/19/25, and 04/09/25. On 04/09/25 at 8:57AM, the surveyor observed Resident #121 sitting in a wheelchair in their room, watching television. With permission from the resident, the surveyor assessed the wheelchair's brakes. Upon unlocking and locking the right break lever, it was noted that the lever did not fully lock the wheel, allowing movement with activity. The left brake lever locked the wheel preventing movement. After exiting 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 · D2025-04-10 · tag F0919 — failed to provide a working call system — isolatedMake sure that a working call system is available in each resident's bathroom and bathing area.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observations and interviews with the facility staff, it was determined that the facility staff failed to ensure that a resident's call bell was within reach. This was evident for 1 resident (Resident #1) out of 4 residents observed during the survey. The findings include: On 4/08/25 at 10:24 AM, the resident was observed lying in bed comfortably. The call bell was noted to be hanging behind the bookcase at the foot of the resident's bed against the wall. The surveyor interviewed the resident and asked he/r, how they would call for assistance. They stated that they uses the call bell. The resident started to look for the call bell and then said, I don't know what I did with it. Then the surveyor asked, How would you ask for assistance if you can't find the call bell? The resident responded that s/he would wait until someone came to check in on them. On 4/09/25 at 1:17 PM, the resident was observed lying in bed, watching TV. The call bell was hanging from the wall on the left side of the bed on the floor. The surveyor went to the nursing station and to interview the Charge…
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 · D2025-01-29 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
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 develop and implement abuse prevention policies to ensure the safety of their residents. This was evident for 1 of 1 facility abuse prevention policies and procedures reviewed. The findings include: During the investigation of facility reported incident #MD00178929, a review of the facility abuse prevention policies and procedures were reviewed on 1/21/25 at 2:15 PM. A review of the facility's Resident Rights - Abuse and Crimes against policy dated 11/13/24, failed to reveal procedures for the implementation of training of new and existing staff, those with contractual agreements, and volunteers to include their expected roles. Further review revealed there was no policy or procedure to establish the coordination with the quality assurance performance improvement [QAPI] program. On 1/22/25 at 11:53 AM, the NHA confirmed that she had provided all the abuse prevention policies and procedures and had confirmed this with the corporate office. The concerns were reviewed with the NHA who responded by stating…
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 · D2025-01-29 · 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 facility staff failed to recognize and report an injury of unknown within the required time frame. This was evident for 1 (#23) of 1 resident reviewed for injury of unknown origin. The findings include: A medical record review for Resident #23 on 1/22/25, at 2:49 PM revealed under the census tab, that the resident had been a long-term resident of the facility. The resident had a care plan initiated on 10/25/23, for the risk of falls related to dementia, lack of safety awareness, and the tendency to constantly reposition themselves to lay sideways or across in the bed. A review of the minimum data set (MDS), with an assessment reference date of 4/16/24, revealed the resident was severely cognitive (the ability to think and process information) impaired. A review of the progress notes revealed that Licensed Practical Nurse (LPN) #40 wrote a note on 6/25/24, at 11:49 AM that she found the resident lying with his/her left leg hanging on the left side of the bed, the resident was repositioned in bed and it was noted that their…
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 · D2025-01-29 · 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 the facility failed to ensure that an allegation of abuse was thoroughly investigated. This was evident for 1 (#8) of 21 residents reviewed for abuse. The findings include: The 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 for Resident #8, on 1/22/25 at 10:30 AM, revealed a minimum data set (MDS) with an assessment reference date of 10/3/22, revealed the resident was not cognitively impaired and relied on staff for activities of daily living (such as toileting, getting in and out of bed, dressing, bathing, and personal care). On 1/22/25 at 10:00 AM, a review of the facility's procedure titled Resident Abuse Reporting and Investigation Guidelines (there was no date on the procedure) revealed in #9 the individual conducting the investigation should: #9a review all the documentation and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-29 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide appropriate treatment and care according to orders, resident’s preferences and goals.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review, interview, and facility policy review, the facility failed to administer a physician ordered medication for 1 (Resident #22) of 3 residents reviewed for medication administration. Specifically, the facility failed to administer a Rocephin (an antibiotic medication) injection to Resident #22 on 02/28/2024. Findings included: A facility policy titled, Medication Administration-General Guideline, revised 12/09/2024, indicated, Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after the have been properly oriented to the facility's medication distribution system (procurement, storage, handling and administration). The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. The policy revealed, B. Administration 2. Medications are administered in accordance with written orders of the prescriber. Per the policy, D.…
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 before2025-01-29 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review, and interview, it was determined that the facility failed to ensure that all staff were wearing mask during a COVID 19 outbreak. This was evident on 1 of 4 floors in the facility. The findings include: Upon entry to the facility on 1/21/25 at the receptionist reported the facility had an outbreak of COVID 19 and masks were required. On 2/24/25, at 6:25 AM, an observation on the transitional care unit [TCU] revealed Geriatric Nursing Assistant (GNA) #7 sitting at a table in an open dining area with no mask on. An interview was conducted with the GNA for approximately 15 minutes, and he failed to put a mask on during this time. In addition, during the interview GNA #42 came over, removed her mask, and sat at the same table. She put her mask back on, left the dining room area, and then came back and removed the mask again. A second observation on 1/24/25, at 6:47 AM revealed Housekeeping Aid (HA) #43 sitting in the common area on the 1st floor with no mask on. The Director of Nursing (DON) walked into the area at the time of the observation. When…
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 before2020-03-13 · tag F0657 — failed to keep the care plan current — patternDevelop 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 review of the clinical record and interviews with residents and facility staff, it was determined that the facility failed to ensure residents and /or representatives participated in care plan meetings and to review and revise care plans as necessary. This was evident for 5of 39 residents (Residents #35, #24, #31, #18, and #118) selected for this survey. The findings include: 1. On 03-10-2020 at 11:05 AM, surveyor interview with Resident #35 revealed the facility had not held a care plan meeting since admission on [DATE]. On 03-11-2020 at 1:00 PM, surveyor review of Resident #35's clinical record revealed a comprehensive admission MDS assessment was completed for Resident #35 on 12-23-2019. There was no documented evidence that a care plan meeting was held with the resident as required. The MDS is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes. On 03-11-2020 at 1:38 PM, surveyor interview with the Administrator…
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 · D2020-03-13 · 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 — an excerpt from the official record, may be distressing
Based on surveyor observations, resident and staff interviews, and clinical record reviews, it was determined that the facility staff failed to treat residents with respect and dignity. This finding was evident for 1 of 2 residents reviewed for the dignity care area during the survey (Resident #287). The findings include: On 03-10-2020 at 12:46 PM, surveyor observed Resident #287 had activated the call system to obtain assistance from facility staff. A visitor was present in the room at the time of surveyor's observation. Surveyor observed that RN staff #1 entered the room and asked Resident #287 how she could help. Resident #287 informed the nurse that his/her back was getting very sore and requested to be repositioned. RN staff #1 informed Resident #287 that there were no repositioning pillows available in the room at this time and she would let the wound care team know to provide repositioning pillows. The visitor asked RN staff #1 if the regular pillows which were available in the room could be used to relieve Resident #287's back pressure. Surveyor observed RN 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.
- Potential for harm · D2020-03-13 · tag F0558 — failed to accommodate residents' needs and preferences — isolatedReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observation, resident and facility staff interview, it was determined that the facility staff failed to keep residents' call lights within reach to allow residents to call for staff assistance. This finding was evident for 2 of 36 residents on the 4 North unit (Residents #77 and #103). The findings include: 1. On 03-09-2020 at 9:19 AM, observation of Resident #77's room revealed the resident's call light rolled up and pinned to the wall, not within the resident's reach. Resident #77 was alert and oriented and stated that, They [staff] always take it away from me. when asked if he/she pinned call light to the wall. The resident said, I can use the call light if they give it to me. A review of Resident #77's clinical record revealed the resident requires assistance from staff for all activities of daily living, except for eating which the resident could perform after the tray was prepared. On 03-09-2020 at 10:25 AM, surveyor reported the observation and Resident #77's response to the unit manager. The unit manager immediately secured Resident #77's call light within…
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 · D2020-03-13 · 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
Based on surveyor observation, clinical record review and staff interview, it was determined that the facility staff failed to develop and implement a baseline care plan for 1 of 39 residents reviewed during the survey (Resident #284). The findings include: On 03-10-2020 at 8:46 AM, surveyor observed Resident #284 with a double lumen central venous catheter on the right upper chest. Resident #284 was on Total Parenteral Nutrition (TPN). A central venous catheter is a thin, flexible tube that is inserted into a vein, usually below the right collarbone, and guided (threaded) into a large vein above the right side of the heart called the superior vena cava. It is used to give intravenous fluids, blood transfusions, chemotherapy, and other drugs. TPN is a method of feeding that bypasses the gastrointestinal tract. Fluids are given into a vein to provide most of the nutrients the body needs. The method is used when a person cannot or should not receive feedings or fluids by mouth. On 03-11-2020, a review of Resident #284's clinical record revealed the resident was admitted to 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 · D2020-03-13 · 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 — the official record, unedited, may be distressing
Based on surveyor review of the clinical records and facility staff interview, it was determined that the facility staff failed to develop a comprehensive resident centered care plan for 1 of 39 residents selected for review during the survey (Resident #77). The findings include: On 03-11-2020 at 11:10 AM surveyor review of the clinical records revealed that on 02-03-2020 Resident #77 was started on antibiotic therapy. Further review of the clinical record revealed that the most recent quarterly Minimum Data Set assessment (MDS) with an assessment reference date (ARD) of 03-02-2020 documented Resident #77 received antibiotics. There was no evidence in the clinical record that the facility staff developed a person-centered plan of care that addressed Resident #77's antibiotic use as referenced in the quarterly MDS . On 03-11-2020 at 11:40 AM interview with the Director of nursing (DON) revealed no additional information.
- Potential for harm · D2020-03-13 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor observation, review of the clinical record, and staff interviews, it was determined that the facility staff failed to weigh 1 of 6 residents reviewed for the nutrition care area (Resident #285). The findings include: On 03-09-2020 review of Resident #285 clinical record revealed an admission weight on 02-29-2020 of 110.4 pounds. On 03-13-2020 further review of the clinical record revealed no other weights had been obtained since admission. On 03-13-2020 at 11:00 AM, interview with the TCU unit manager revealed that the facility protocol is to obtain weights weekly for a total of four (4) weeks post admission. The unit manager stated all weights on the TCU are conducted on Wednesdays, and that Resident #285 should have been weighed on 03-04-2020 and 03-11-2020. On 03-13-2020 at 11:15 AM Resident #285 was weighed by facility staff. The current weight was documented as 107.4 pounds, a 3 pound weight loss since admission on [DATE]. The unit manager notified the facility dietitian of the weight loss.
- Potential for harm · D2020-03-13 · tag F0757 — failed to avoid unnecessary drugs — isolatedEnsure each resident’s drug regimen must be free from unnecessary drugs.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and surveyor interview, it was determined that the facility staff failed to adequately monitor residents receiving antipsychotic medications for side effects, and failed to attempt a gradual dose reduction of psychotropic medication. This finding was evident for 2 of 5 residents reviewed for unnecessary drugs (Residents #9 and #118). The findings include: 1. On 03-12-2020 review of the clinical record for Resident #9 revealed that the resident received antipsychotic medication with no evidence in the clinical record that facility staff were monitoring the resident for side effects associated with use of the medication. In addition, a review of the clinical record revealed that on 10-23-2019, the psychiatrist documented a plan to delay the gradual dose reduction (GDR) for one of Resident #9's psychotropic medications due to an upcoming surgery. The psychiatrist assessed Resident #9 on 12-04-2019 (after the surgical procedure had been completed); however, there was no evidence that the resident was re-evaluated for a GDR after the surgery. On 03-12-20 at 01:47…
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 · D2020-03-13 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 surveyor observation and staff interviews, it was determined that the facility staff failed to serve food under sanitary conditions. This finding was evident in the facility's dining room on the second floor north dining room, and on the fourth-floor during the lunch observation. The findings include: 1. On 03-09-2020 at 12:20 PM surveyor observed Staff #10 in the dining room when lunch was being served. Staff #10 was observed pushing residents in wheelchairs to position them at their respective dining tables. Staff #10 was observed moving from table to table assisting with positioning the residents. Continued observation revealed Staff #10 delivered and set up the residents' meals without washing their hands or using hand sanitizer. Staff #10 sat down and was observed assisting the residents with their meal. Surveyor observation of the dining room revealed a hand sanitizer mounted on the wall at the entrance of each doorway into the dining room opposite the kitchenette. However, Staff #10 washing hands or applying hand sanitizer at any time while repositioning residents or…
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 before2020-03-13 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on surveyor observations, clinical record review and staff interview, it was determined that the facility staff failed to follow standard and transmission-based precautions to prevent spread of infection while providing care. This finding was evident for 1 of 7 units in the facility. The findings include: 1. On 03-09-2020 at 8:37 AM, surveyor observed GNA staff #4 was in Resident #436's room with a nursing student. GNA staff #4 pulled the resident up on bed with help of the nursing student. She then helped the resident to set up the breakfast tray. Both GNA staff #4 and the nursing student did not wash their hands prior to leaving the room. On 03-09-2020 at 9:40 AM, surveyor observed GNA staff #4 pushing Resident #218 in a wheelchair in the hallway. While passing by in the hallway, GNA staff #4 entered Resident #211's room and assisted Resident #211 with items on his/her overbed table. Upon completing the task, GNA staff #4 left the room without washing her hands and continued pushing Resident #218's wheelchair to their room. Upon arrival in Resident #218's room, GNA staff #4…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ASBURY COMMUNITIES — 5 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 5 of 5 | 5.0 | ≈ chain avg |
| Health inspection | 5 of 5 | 4.6 | +0.4 vs chain |
| Staffing | 5 of 5 | 4.6 | +0.4 vs chain |
| Quality measures | 4 of 5 | 4.4 | -0.4 vs chain |
The other 4 homes this chain runs (chain average 5.0★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| ASBURY COMMUNITIES INC | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; ADP OF THE SNF | 100% | since 06/01/2006 |
| ANDREWS, TODD | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 01/01/2021 |
| HARBISON, BARBARA | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| HILL-MILBOURNE, VERONICA | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| MATUS GARCIA, MARIANA | Individual | CORPORATE DIRECTOR | — | since 01/01/2025 |
| SHUMAN, RICHARD | Individual | CORPORATE DIRECTOR | — | since 01/01/2023 |
| SPROLES, EFONDA | Individual | CORPORATE DIRECTOR | — | since 01/01/2021 |
| JEANNERET, ANDREW | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 12/07/2017 |
| JOSEPH, ANDREW | Individual | CORPORATE OFFICER; ADP OF THE SNF | — | since 01/02/2001 |
| KRUTH, RACHEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | — | since 04/04/2025 |
| TAVAKOLI-JALILI, NADER | Individual | ADP OF THE SNF | — | since 04/04/2025 |
CMS files one row per role, so the 18 rows in the source record cover these 11 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.
This home reported $975K paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in MD
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Maryland Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215099. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-05-01, 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 →
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