Sacred Heart Home INC
5805 Queens Chapel Road, Hyattsville, MD 20782 · Non profit - Church related · 44 certified beds · (301) 277-6500 Medicaid only — no Medicare
On the public record, this home looks stronger than most — but visit before you decide.
- 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 (9% 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 a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — 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 (19) — 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 |
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 | 20.6% | 20.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 2.5% | 5.4% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.0% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 1.1% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 22.8% | 6.5% | check this* — see note marked star 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 | 5.2% | 2.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 33.8% | 22.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 21.8% | 16.7% | 18.9% | worse |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 1.2% | 5.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 23.2% | 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 |
| Long-stay hospitalizations per 1,000 resident days | 1.03 | 1.33 | 1.67 | better |
| Long-stay outpatient ER visits per 1,000 resident days | 0.65 | 1.20 | 1.80 | better |
* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
Therapy staffing: this home’s payroll records show 0.31 therapist hours per resident per day in 2026Q1 — more than 51% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 0% 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 | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — This nursing home is not required to submit data for the Skilled Nursing Facility Quality Reporting Program. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 44 beds and averages 43.3 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. 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 4.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 3.10 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 4.33 hrs/resident/day on weekends vs 5.07 on weekdays — 15% thinner on weekends. RN hours go from 0.65 to 0.38 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 9% 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.
19 citations, most serious first. The 10 most serious are shown; the remaining 9 are one tap away and print in full.
- Potential for harm · Fcited before2025-07-29 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff, it was determined that the facility failed to ensure that food items were labeled and dated. This was found to be evident during the facility's annual Medicare/Medicaid survey and has the potential to affect all residents eating food prepared in the facility's kitchen.The findings include:On 07/24/2025 at 7:41 AM, during the initial tour of the main kitchen of the facility with the Dietary Manager Staff #2 accompanying the surveyor, inside the stand-alone refrigerator were unlabeled and undated sausages and fried eggs in separate bowls. Staff #2 confirmed that they were eggs used for puree and that the sausages were left over but the staff who had made the food forgot to date and label it. Staff #2 took the food items out of the refrigerator.On 07/24/2025 at 7:48 AM, during a continued tour of the kitchen. Inside the walk-in freezer, the following items were observed, there was a bag of frozen sausages, two bags of chicken drumsticks, one bag of chicken…
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 · F2022-12-14 · tag F0947 — failed to train nurse aides adequately — widespreadEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on documentation review and interview, it was determined that the facility failed to ensure nurse aide competency training (including dementia management and resident abuse prevention training) occurred no less than 12 hours per year. This was evident for 3 of 3 employee training records reviewed and had the potential to affect all residents. The findings include: A review was conducted of GNAs' (Geriatric Nurse Aide) training records from 2019 to current on 12/09/22 at 8:00 AM. A review of GNA #35's personnel file revealed GNA #35 was hired in November 2006. A review of GNA #36's personnel file revealed GNA #36 was hired in July 2004. A review of GNA #37's personnel file revealed GNA #37 was hired in March 2010. During an interview with Staff #2 (Minimum Data Set Coordinator, Infection Control Preventionist, also an educator) on 12/09/22 at 08:54 AM, she stated the facility did not document staff's education records in their employee files. Staff #2 confirmed that instead of filing under the personal file, the facility saved in-service sign-in sheets for all staff'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 · E2022-12-14 · tag F0700 — patternTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based upon observations, record review, and facility staff interviews, it was determined that the facility failed to 1) have a system in place to ensure the appropriate use and implementation of side rails and bed rails, 2) have accurate assessments that correlate with the physician orders and 3) have consents that correlate with the actual need of the use for side rails. This was evident for 3 of 3 residents reviewed for accident hazards (#8, #14, #34). The findings include: 1. During tour of the third floor, Resident #8 was observed on 11/30/22 at 10:26 AM and 12/01/22 09:41 AM with the bed positioned at a 45-degree angle with bilateral (both) upper half length bed rails with bilateral padding that failed to extend to the upper ¼ of the bed rails, leaving this portion of the rails exposed with no protective padding. On 11/30/22 10:53 AM, this resident was observed leaning to the right side with his/her call bell on the floor under the bed. Medical record review of Resident #8 on 12/12/22 at 10:05 AM revealed diagnoses including: dementia, history of other mental and behavioral…
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 before2022-12-14 · tag F0812 — failed to store, cook, and serve food safely — patternProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview with facility staff, it was determined that the facility failed to: 1) keep complete kitchen records and, 2) store food in accordance with professional standards for food service and safety. This was evident of 3 out of 4 observations of food storage during the annual survey. The findings include: 1) On 11/30/22 at 10:33 AM, the surveyor conducted an initial tour of the kitchen in the presence of the Food Service Director (staff #32). The surveyor observed Kitchen Staff #12 passing dishes through the dishwasher. When asked about the process for verifying temperature and sanitizer levels for the dishwasher, Staff #12 was able to demonstrate how to take the temperature on the dishwasher and able to demonstrate application of a testing strip to monitor the chlorine levels. Staff #12 then stated the temperatures and chlorine levels are logged before each dishwasher run and whomever is working in this area is responsible for recording the readings. The surveyor reviewed the dishwasher logbook and noted November written on the top of the first log page.…
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 · E2022-12-14 · tag F0909 — failed to maintain a comfortable temperature — patternRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview of facility staff, observations, and record review, it was determined that the facility failed to implement a process for conducting regular inspection of bed rails as part of a regular maintenance program to identify areas of possible entrapment. This was evident for 3/3 residents (Resident #8, Resident #14, Resident #34) reviewed for bed rails. This has the potential to affect all residents who utilize bedrails. Regular maintenance checks and inspection of bed rails are necessary to ensure the highest degree of safety for both residents and the facility staff who assist them. Bed rails can shift and loosen over time, and possible areas of entrapment must be identified to prevent potential injury and harm to residents. The findings include: Interview with the Maintenance Director, Staff#16, on 12/07/22 at 11:05 AM revealed that the facility looks at rooms every turn-over when a resident expires. However, regular routine maintenance documentation of inspection of bedrails does not exist unless there is a problem/work order placed for it. When asked for…
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 · D2022-12-14 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview with facility staff, it was determined that the facility failed to develop and implement a person-centered comprehensive care plan to meet and address a medical need. This was evident for 1 of 3 residents observed for visual aids (Resident #8). The findings include: A person-centered comprehensive care plan addresses the unique needs of each resident. It is a valuable tool which must reflect immediate steps utilized to direct the approach to support the patient to achieve and maintain their highest practicable level of functioning and well-being. The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Review of the medical record for Resident #8 on 12/01/22 at 10:36 AM revealed the patient requires a visual aid per the 1/14/22 annual MDS under section 'B1000' for vision, noted that s/he had…
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 · D2022-12-14 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on random observations it was determined that the facility failed to maintain an environment free of accident hazards. This was evident during 3 random observations of the second floor. The findings include: 1. During a tour of the third floor on 12/1/22 at 9:39 AM, Surveyor observed an unattended and unlocked medication cart open in front of room [ROOM NUMBER]. Surveyor stood and monitored the medication cart for 5 minutes until Licensed Practical Nurse (LPN) #14 approached and asked if she could provide the surveyors with any assistance. The surveyor brought the unlocked medication cart to her attention and she confirmed that the cart was unlocked and stated that the nurse assigned to the cart was currently down the hall. 2. During a tour of the third floor on 12/6/22 at 9:45 AM until 9:49 AM, Surveyor observed an unlocked and unattended medication cart located outside of room [ROOM NUMBER]. At 9:49 AM LPN #20 exited room [ROOM NUMBER] that was on isolation. LPN #20 was asked if this was her medication…
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 · D2022-12-14 · tag F0825 — isolatedProvide or get specialized rehabilitative services as required for a resident.
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 resident's medical records and interview with facility staff, it was determined that the facility failed to provide rehabilitative services according to residents' comprehensive care plans for residents on isolation for COVID-19. This was evident of 2 out of 2 residents reviewed rehabilitation services (Resident #21 & Resident #25). The findings include: On 12/2/22 at 12:04 PM, the surveyor reviewed Resident 21's medical record. The review revealed that Resident #21 had diagnoses that included: age-related osteoporosis, osteoarthritis of both knees, difficulty in walking and muscle weakness. Further review of the record revealed an order written on 11/22/22 for Resident #21 stating, Physical Therapy (PT) recertification orders; continued skilled physical therapy 1-3 weeks for 30 days. On 12/5/22 at 12:27 PM, the surveyor reviewed Resident #25's medical record. The review revealed Resident #25 had diagnoses that included: unequal limb length, unspecified abnormalities of gait and mobility,…
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 before2022-12-14 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview with facility staff, it was determined that the facility failed to maintain consistent and accurate medical records. This was evident for 1 of 3 residents reviewed for falls (Resident # 38) and 2 of 3 residents reviewed with skin conditions (Resident #3 and Resident #39). The findings include: 1. Resident #38 was observed and reviewed secondary to his/her random selection into the initial pool process for the annual survey. Resident #38 was first observed on 11/30/22 at 10:09 AM sitting in bed and was able to answer a few questions. S/he did state that s/he had not had any falls recently and has not been to the hospital. A review of Resident #38's medical record on 11/30/22 at 11:59 AM revealed that a Fall Risk Assessment was completed on 10/23/22. Under #1 for history of falls, during the last 90 days, the resident has had how many falls; '0' was selected for no falls although 8/26/22 was entered in the auto populated space under #1 as the date of the most recent fall. Further review of the 2-page assessment compared to the fall…
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 · D2019-01-25 · 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 record review and interview it was determined the facility staff failed to promote and enhance a resident's dignity and rights by obtaining weights on Resident (#22). This was evident for 1 of 28 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #22 revealed on 4/19/18 the physician ordered: no weight monitoring. Further record review revealed the facility staff obtained and documented weights on the resident on: 4/25/18 and 5/6/18. Interview with the Director of Nursing on 1/25/19 at 2:00 PM confirmed the facility staff failed to honor the wishes of Resident #22 by obtaining weights when there was an order for no weights.
Show the remaining 9 citations
- Potential for harm · D2019-01-25 · 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 staff interview it was determined the facility failed to thoroughly investigate an injury of unknown origin and report that injury of unknown origin to the Office of Health Care Quality for Resident (#10). This was evident for 1 of 28 residents selected for review during the annual survey process. The findings include: The purpose of a thorough investigation is first to determine if abuse of the resident has occurred. It is the expectation that any allegation of abuse or injury of unknown occurrence being investigated by the facility and be reported to the appropriate agency within 24 hours and the conclusion of the investigation to be reported in 5 days to the appropriate agency (OHCQ) and the Office of Aging (Ombudsman). Medical record review for Resident #10 revealed on 11/22/18 at 11:45 the facility staff documented: Resident was observed with dislocation to left breast.11x9; however, the facility staff failed to thoroughly investigate the injury of unknown origin or report that injury to the Office of Health Care Quality. (Of note, the facility staff…
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 · D2019-01-25 · 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
Based on medical record review and interview with staff it was determined that the facility staff failed to provide a written notice for emergency transfers to the resident and/or the resident representative. This was found to be evident for 2 out of 3 residents reviewed for a facility-initiated transfer during the investigative portion of the survey. The findings include: 1. A medical record review for Resident # 27 was conducted on 01/23/19. Review of the physician order written on 11/25/18 revealed that Resident # 27 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical record failed to reveal a written notice for emergency transfers to the resident, resident representative and the ombudsman. 2. A medical record review for Resident # 41 was conducted on 01/23/19. Review of the physician order written on 12-17-18 revealed that Resident # 41 had a change in their medical condition that required an immediate transfer to an acute care hospital for further evaluation. Review of the medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-01-25 · tag F0773 — isolatedProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, it was determined the facility staff failed to obtain a physician's order prior to obtaining laboratory blood test on Resident #77. This was evident for 1 of 28 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #77 revealed on 1/9/19 the facility staff obtained a CBC. A complete blood count (CBC) is a blood test used to evaluate the overall health and detect a wide range of disorders, including anemia, infection and leukemia. Some components of the CBC include: Red blood cells, which carry oxygen White blood cells, which fight infection Hemoglobin, the oxygen-carrying protein in red blood cells Hematocrit, the proportion of red blood cells to the fluid component, or plasma, in your blood Platelets, which help with blood clotting It was further noted the physician was notified of the CBC results on 1/19/19 with no new orders; however, the facility staff failed to obtain a physician's order for the CBC prior to obtaining the laboratory blood test. Interview with 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 before2019-01-25 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview, it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for Resident (#77). This was evident for 1 of 28 residents selected for review during the annual survey process. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. Medical record review for Resident # 77 revealed the following documented by the facility staff on 1/17/19 at 22:38 (10:38 PM): PMD (physician) was called, the medical director was also called and the female PMD too was called to review Resident's lab result but there was no response. currently awaiting PMD's call. Further record review revealed no evidence any of the physicians' called were notified of the laboratory results as indicated in the original phone call. Interview with the Director of Nursing on 1/25/19 at 2:00 PM confirmed the facility staff failed to maintain the medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-01-25 · 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 review of newly hired employees, it was determined the facility staff failed to screen the registered dietician for MMR, Varicella or Hepatitis B. This was evident for 1 of 5 employee records reviewed during the annual survey. The findings include: Measles is a very contagious respiratory infection. It causes a total-body skin rash and flu-like symptoms. Mumps is a viral infection that primarily affects saliva-producing (salivary) glands that are located near your ears. Mumps can cause swelling in one or both glands. Rubella - commonly known as German measles or 3-day measles - is an infection that mostly affects the skin and lymph nodes. It is caused by the rubella virus (not the same virus that causes measles). Varicella-chickenpox is a very contagious disease caused by the varicella-zoster virus (VZV). It causes a blister-like rash, itching, tiredness, and fever. Hepatitis B is a serious liver infection caused by the hepatitis B virus (HBV). Review of newly hired employees revealed the registered dietician was hired 10/6/18; however, facility staff failed to screen 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.
- No harm found · C2022-12-14 · tag F0732 — widespreadPost nurse staffing information every day.
What the surveyor found here — the official record, unedited, may be distressing
Based on surveyor observation and interview with facility staff, it was determined that the facility staff failed to post the required staffing information in a prominent place readily accessible to residents and visitors. This was evident for 2 (1st floor and 3rd floor) of 2 resident care areas observed during the annual survey. The finding includes: The surveyor conducted daily observation in the facility residents care area (1st floor and 3rd floor) from 12/5/22 to 12/14/22. The surveyor was not able to find the staffing information posted in a prominent place accessible to residents and visitors. During an interview with the Nursing Home Administrator (NHA) on 12/09/22 at 9:28 AM, the NHA stated the facility had actual staffing posted on each unit. The surveyor asked about the federal regulation requirements information: total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift. The NHA could not provide any documentation regarding the staffing information, including details.
- No harm found · C2022-12-14 · tag F0849 — widespreadArrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice 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 the review of facility records, facility policy, and interviews with facility staff, it was determined that the facility failed to: 1. have a written agreement with a hospice provider prior to any hospice services being furnished in the facility, and 2. have a designated staff member responsible for coordination of care with hospice staff. This was evident of 1 of 2 hospice service agreements reviewed. The findings include: The Centers for Medicare and Medicaid defines Hospice as a comprehensive, holistic program of care and support for terminally ill patients and their families. Hospice care changes the focus to comfort care (palliative care) for pain relief and symptom management instead of care to cure the patient's illness. Facilities are required to ensure that each resident receiving hospice services first has an agreement signed by the hospice provider and the facility delineates responsibilities and expectations for hospice care. Additionally, facilities are required to include, as part of 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.
- No harm found · C2022-12-14 · tag F0883 — failed to offer flu and pneumonia vaccines — widespreadDevelop and implement policies and procedures for flu and pneumonia vaccinations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review for residents, review of the facility policies, and staff interview, it was determined that the facility staff failed to develop the policies and procedures to ensure residents or responsible parties receive education regarding the benefits and potential side effects of Influenza immunization. This was found to be true in a review of the facility's Influenza vaccination policy during the annual survey. The findings include: Flu (also known as influenza) is a contagious disease that spreads around the United States every year, usually between October and May. Anyone can get the flu, but it is more dangerous for some people. Infants and young children, people 65 years and older, pregnant people, and people with certain health conditions or a weakened immune system are at the greatest risk of flu complications. Influenza (Flu) vaccines can prevent influenza. [Centers for Disease Control and Prevention- vaccines and preventable disease] On 12/05/22 at 11:54 AM, the surveyor reviewed the facility's Influenza Vaccination policy. The policy submitted by 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.
- No harm found · C2022-12-14 · tag F0888 — widespreadEnsure staff are vaccinated for COVID-19
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interviews with facility staff, and a review of the facility's policies and procedures, it was determined that the facility failed to implement their policies and procedures for contingency plans for staff who are not fully vaccinated for COVID-19. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The finding includes: During an interview with the Infection Control Preventionist (ICP) on 12/05/22 at 10:20 AM, she stated the facility had two staff with religious exemptions COVID-19 vaccine. The ICP explained that two Nonvaccinated staff had the same assignment as vaccinated staff and were encouraged to have N-95 masks regardless of COVID-19 outbreak status. Also, the ICP said, they were pretty good for hygiene and precaution before the vaccination was required. A policy and procedure titled Coronavirus Disease (COVID-19)- Vaccination of Staff indicated interpretation and implementation for Nonvaccinated staff. However, it did not include contingency plans for staff who are not fully vaccinated for COVID-19. On 12/06/22 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.
“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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| Ownership Data Not Available |
The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.
What families pay in MD
CMS lists this home as Medicaid-certified only — it can accept Medicaid for long-term care, but it is not Medicare-certified, so Medicare will not pay for a short rehabilitation (“skilled nursing”) stay here. 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 21E009. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-29, 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.