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Oak Crest Village

8800 Walther Boulevard, Parkville, MD 21234 · Non profit - Corporation · 80 certified beds · (410) 882-3248 Medicare & Medicaid certified

Call the home — (410) 882-3248 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Sep 20243 actual-harm citations$49,725 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
  • a high payroll-based staffing rating (4/5)
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Sep 2024
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 3 actual-harm citations
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $49,725 in federal fines (most recent 2024-09-06)

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.

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

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
8615 Ridgelys Choice Dr · (410) 256-3200 · Call to confirm hours
Pharmacy
8800 Walther Blvd · (410) 882-3238 · Call to confirm hours
Grocery
Food Lion0.3 mi
8635 Walther Blvd · (410) 663-3207 · Call to confirm hours
Park
9736 Harford Rd · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 5 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased28.4%20.4%15.4%worse
Long-stay residents who lose too much weight3.6%5.4%5.4%better
Long-stay residents with a catheter left in their bladder2.7%0.5%0.9%worse
Long-stay residents with a urinary tract infection4.0%1.5%2.0%worse
Long-stay residents with depressive symptoms0.3%22.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury7.2%2.4%3.3%worse
Long-stay residents whose ability to walk worsened38.9%22.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication15.1%16.7%18.9%better
Long-stay residents given the seasonal flu vaccine97.2%96.6%95.3%typical
Long-stay residents with pressure ulcers4.0%5.9%4.7%better
Long-stay residents with worsening bladder/bowel control20.1%25.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table21.9%13.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication1.4%1.1%1.4%typical
Short-stay residents given the seasonal flu vaccine89.8%80.6%79.4%better
Short-stay residents rehospitalized after admission13.1%21.0%22.6%better
Short-stay residents with an outpatient ER visit6.6%9.8%12.0%better
Long-stay hospitalizations per 1,000 resident days1.131.331.67better
Long-stay outpatient ER visits per 1,000 resident days0.291.201.80better

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

66.6% 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 355 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

66.6%U.S. median 51.5%
Got home and stayed home
11.1%U.S. median 10.7%
Went back to hospital
63.9%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.18hours / resident / day
Physical therapy
0.17hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 63.9% 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 122 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 0.41 therapist hours per resident per day in 2026Q1 — more than 71% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 12% 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
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF66.6%CMS range 61.0–70.651.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF11.1%CMS range 7.9–14.010.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge63.9%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge51.6%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge59.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS 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 discharge100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.4%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.8%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization7.2%CMS range 4.7–10.87.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.801.02Oct 2022–Sep 2024CMS makes no comparison for this measure

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

Staffing

1.01
RN hours/ resident / day
0.72
LPN hours/ resident / day
2.66
Aide hours/ resident / day
4.39
Total nurse hours/ resident / day
0.71
RN hoursweekends
50.0%
Total nursing turnover
43.5%
RN turnover

How full it usually is: this home is certified for 80 beds and averages 77.0 residents a day — about 96% occupied, or roughly 3 beds 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 4.39 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.01 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.66 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 4.01 hrs/resident/day on weekends vs 4.54 on weekdays — 12% thinner on weekends. RN hours go from 1.13 to 0.71 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 50% is about the same as the national median of 45%.

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

Inspection trend

0
deficiencies at the latest standard inspection (2026-02-12)
11
at the previous standard inspection (2024-09-06)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

26 citations, most serious first. The 13 most serious are shown; the remaining 13 are one tap away and print in full.

  • Actual harm · G2024-09-06 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and review of facility investigation documents, it was determined that the facility failed to ensure that residents remained free of abuse and neglect. This failure led to physical abuse and harm of Resident #135. This finding was evident for 5 of 34 (Resident #135, #130, #117, #122, #125) residents reviewed for abuse during the survey. The findings include: The facility's investigation related to facility-reported incident MD00191125 was reviewed on 8/28/24 at 2:39 PM. In the investigation, the facility substantiated there was an altercation between Resident #132 and Resident #135 which led to Resident #135 sustaining multiple injuries. On 8/29/24 at 12:15 PM review of Resident #132's Hospital #3 (inpatient psychiatric hospital) Discharge summary dated [DATE] revealed a diagnosis of dementia with behavioral disturbance, agitation and aggression and relapse of illness. It was documented, Patient presented to the ER (emergency room) due to agitation and paranoid…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-09-06 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff interviews, and review of facility investigation documents, it was determined that the facility failed to provide adequate supervision to Resident #132 who had a documented history of wandering, agitation, and physically aggressive behaviors as evidenced by the physical abuse and harm of Resident #135. This was evident for 1 (Resident #132) of 4 residents reviewed for accidents and adequate supervision during the survey. The findings include: The facility's investigation related to facility reported incident MD00191125 was reviewed on 8/28/24 at 2:39 PM. In the investigation, the facility substantiated there was an altercation between Resident #132 and Resident #135 which led to Resident #135 sustaining multiple injuries. On 8/29/24 at 12:15 PM review of Resident #132's Hospital #3 (inpatient psychiatric hospital) Discharge summary dated [DATE] revealed a diagnosis of dementia with behavioral disturbance, agitation and aggression and relapse of illness. It was documented,…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-09-06 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, administrative reviews, and staff interview, it was determined that facility staff failed to monitor and implement interventions to address the nutritional needs of residents who had a known significant weight loss. This deficient practice was evident for 5 (#127 and #22, #17, #40, #33) out of 15 residents reviewed for nutrition. The failure resulted in harm to Resident #127. The findings include: 1. On 8/30/24 at 10:47 AM, a review of the facility reported incident MD00201638 dated 01/18/24 alleged Resident #127 was being neglected by staff due to the resident's significant weight loss. Review of medical records on 8/30/24 at 11:10 AM revealed a clinical note dated 1/12/24 at 2:25 PM from Registered Dietitian (RD) #36 revealed that Resident #127 was noted to have lost 15.23% of their weight over 30 days, 28.49% over 90 days and 26.01% over 180 days. A dietary intervention was added to Resident #127's plan of care on 01/12/24 which included an in-house milkshake at 2pm. Review of…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-10 · tag F0552 — isolated
    Ensure that residents are fully informed and understand their health status, care and treatments.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the clinical record and interviews, facility staff failed to fully inform the Power of Attorney (POA) of a resident before conducting a diagnostic procedure. This finding was evident for one (Resident #16) out of six residents reviewed for injury of unknown origin during this complaint survey.The findings include:On 10/08/25 at 8:03 AM, the surveyor reviewed self-reported incident #312142, which was reported on 12/22/24 regarding Resident #16's possible disarticulation (fracture or dislocation) of the left knee. The report showed that a facility nurse noted the significant changes on 12/22/24, and Resident #16 subsequently received an X-ray.Further review of Resident #16's medical records and the facility's incident report on 10/08/25 at 8:30 AM revealed that the resident's spouse was the Power of Attorney (POA) and that the resident had received hospice care since October 2024.On 10/08/25 at 11:23 AM, the surveyor requested and reviewed documentation from hospice. The review revealed that Resident #16 was seen by hospice nurse (Staff #17) on 12/02/24, who noted:…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-10 · tag F0583 — failed to protect personal privacy — isolated
    Keep 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 surveyor observation and interview with staff, it was determined that the facility staff failed to protect the privacy of residents' medical information. This was found to be evident in 1 out of 3 nursing units observed during a complaint survey.The findings include:On [DATE] at 8:10 AM the surveyor observed a cart with a laptop, two pieces of paper, a plastic pitcher of water, 3 small containers (applesauce, vanilla pudding and chocolate pudding), and a pill crusher. The laptop screen was open with patient information visible in the hallway in front of room NG S335. Furthermore, the top paper on the cart had medical information of 11 residents visible that included their MOLST status (Medical Orders for Life-Sustaining Treatment: a medical document that contains a patient's wishes for life-sustaining medical treatments, like CPR and artificial ventilation), their diet, medications, and other important info (as observed on the paper). During the next 7 minutes, the surveyor stood by the cart and heard…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-10 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical records review and staff interview, it was determined the facility staff failed to revise interdisciplinary care plans to reflect accurate interventions for residents. This was evident for one (Resident #21) of the six residents reviewed for injuries of unknown origin during this complaint survey.The findings included:On 10/06/25, at 2:07 PM, the surveyor reviewed facility's self-reported incident (312135) concerning Resident #21, who reported bruises on both arms on 11/04/24. The facility staff investigated this as an unknown origin of injury and concluded that the bruises resulted from Resident #21 propelling their wheelchair, during which their arms hit and rubbed against the wheelchair and the wheelchair brake extenders. In an interview with the Rehab Director (Staff #4) on 10/07/25, at 11:13 AM, he verified that Resident #21's initial evaluation, dated 5/22/24, stated that the resident required assist but was able to self-propel wheelchair. Furthermore, after the incident reported on 11/04/24, a therapist assessed Resident #21 and verified that self-propelling…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-10 · tag F0676 — failed to keep up residents' daily-living abilities — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a complaint and of the medical record, interviews with facility staff, and observation, it was determined the facility failed to provide assistive devices to residents that would allow the residents the ability to achieve the greatest independence with performing Activities of Daily Living (ADL). This was evident for 1 (#312111 regarding Resident #8) of 5 complaints reviewed during the complaint survey. The findings include:Activities of Daily Living (ADLs) are the basic, essential self-care tasks people need to perform to maintain their health, safety, and well-being, such as bathing, dressing, eating, and toileting.The Minimum Data Set (MDS) is a federally mandated, standardized assessment tool used to comprehensively evaluate a resident's health status, functional abilities, and needs. It is administered to all residents upon admission, quarterly, yearly, and whenever a significant change in an individual's condition occurs. It is the foundation for creating an individualized care plan 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-10-10 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of a complaint and of the medical record, interviews with facility staff, and observation, it was determined the facility failed to provide supplements as documented in a resident's care plan and Dining Detail. This was evident for 1 (#312111 regarding Resident #8) of 5 complaints reviewed during the complaint survey. The findings include:A document titled, Dining Details Report- Supporting Nutritional Care provided by the Nursing Home Administrator (NHA) was reviewed on 10/9/25 at 8:10 AM. The review revealed, The Dining Details Report (DDR) is a document that is printed by dining leadership from myUnity (the facility's electronic medical record). Because this report comes directly from the electronic medical record, it contains the most current diet orders, dining preferences, allergies, and all the other details necessary to provide accurate and quality nutritional care for a resident. Review of complaint 312111 on 10/7/25 at 10:01 AM revealed the complainant noted that Resident #8 did not…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-10 · tag F0849 — isolated
    Arrange 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

    Based on investigation of complaints, medical records review, and staff interviews, it was determined that the facility failed to coordinate care for a resident receiving hospice services. This was evident that one (Resident #16) of 22 residents reviewed for their care during this complaint survey.The findings include:On 10/08/25, at 8:03 AM, the surveyor reviewed Self-Reported Incident #312142, which stated that on 12/22/24, Resident #16 was noted having a swollen left knee, and an X-ray was ordered for follow-up.Further review of the facility's investigation report showed that the Nursing Home Administrator (NHA) submitted the follow-up incident report on 12/26/24, with a summary of the incident: On November 27, 2024, the resident was noted with swelling to the left knee. It was red, warm to the touch, and the NP diagnosed the resident with cellulitis. The resident was started on an antibiotic and ibuprofen for infection, pain, and inflammation. On December 2, 2024, the resident's knee had further swelling and pain. A Hospice nurse assessed the resident and noted that the left…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-10-10 · tag F0943 — isolated
    Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility reported incidents, review of employee records, and interview with facility staff, it was determined that the facility failed to have documentation that a Care Associate (CA) was given abuse training after returning from suspension related to an allegation of abuse. This was evident for 1 (CA #18) of 2 Care Associates records reviewed during this complaint survey.The findings include:On 10/9/25 at 10:05 AM a review of a Facility Reported Investigation (FRI) noted that Resident # 2 complained that on 6/11/25 evening shift, a Care Associate (CA) pushed and pulled him around and unplugged his television. The resident denied pain at time of assessment and the resident's wife stated that resident appeared more confused, however the resident was able to provide a description of the CA #18.An interview was conducted with CA #18 on 6/12/2025 who stated that he/she had received report from the nurse to be very careful with the resident's Left arm. Resident was sitting in a chair and was assisted with changing his/her clothes and transferred to bed. CA #18 further…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-06 · tag F0609 — failed to report abuse allegations — widespread
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    5. On 09/03/24 at 3:00 pm review of the facility's investigation of Resident #122 alleged allegation of abuse revealed there was not a date on the reporting form to verify when the facility reported the incident to the state agency. There was no email to verify the date and time the incident was sent to OHCQ. Administrator #1 was made aware and asked to provide documentation of when the state agency was made aware of the allegation of abuse. On 09/04/24 at 08:16 am received a copy of the email when the incident concerning Resident #122 was reported to OHCQ. The incident was reported on 12/20/23 at 1:30 pm. Per documentation provided by the facility, Administrator #1 was made aware of the incident on 12/20/23 at 9:30 am. The alleged allegation of abuse was reported to the state agency outside the allotted 2-hour timeframe. 6. On 09/04/24 at 9:34 am a review of the facility's investigation of the incident involving Resident #129 revealed the self-report did not indicate when the report was submitted to the state agency; Administrator #1 & Director of Nursing # 8 were made aware. On…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-06 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, staff interviews and record review, it was determined that the kitchen failed to store food items so as to maintain the integrity of the specific item and failed to wear gloves while preparing food. This was observed during the initial tour of the kitchen. The findings include: On 08/26/2024 at 7:55 AM an initial tour of the kitchen was done with the Certified Dietary Manager (CDM) Staff # 76. The following concerns were identified: 1. Unlabeled opened cooking oil container on the shelf in the dry kitchen. 2. The cook (staff #77) was observed not wearing gloves while handling and preparing food on food trays. When asked, he placed gloves on without practicing hand hygiene. 3. A Full container of prepared soup was observed covered with plastic and without a date on top. 4. Cooked stuffed cabbage, ground beef, cheese, and burgers beyond expiration dates were found in the freezer. As this surveyor pointed these things out, Staff #76 was throwing the expired food away. 5. The three compartment sink Sanitizer Test Strips were observed wrapped with aluminum foil…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-06 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, resident interviews, and staff interviews, It was determined that the facility failed to treat the resident with dignity by improperly turning the resident. This was evident for 1 (resident #5) of 9 residents reviewed for dignity. The findings include: On 8/27/24 at 10:50 AM, an interview was conducted with Resident #5. The resident stated that s/he remembered an incident involving a staff member a while ago but could not remember the staff member's name. The resident stated, It seems like they took care of her though because I haven't seen her. On 8/28/24 at 1:40 PM, the Facility Reported Incident (FRI) MD00205236 was reviewed. The allegation reported was physical abuse from a staff member to the resident. The facility reported that a Geriatric Nursing Assistant (GNA) noticed Resident #5 to have multiple bruises on arms. On 8/28/24 at 1:50 PM, the facility's 5-day investigation report was reviewed. The facility reported to have interviewed all staff who worked with the resident in the past 72 hours from the date the bruises were reported, which was 7/7/2024…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 13 citations
  • Potential for harm · D2024-09-06 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and staff interview, the facility failed to accommodate the resident's (#22) dietary needs. This was evident for 1 of 2 residents reviewed for nutrition. The findings include On 9/5/24 at 12:10 PM, Resident #22's meal ticket was reviewed. The meal ticket states, Equipment: Need Assistance --- opening everything. Need Assistance ---cut the food. Supplements: 8pm - Snack, Super cereal at B [breakfast], L/D [lunch/dinner]: 2 desserts, 2pm: in-house milkshake, L [lunch]: ice cream. On 9/5/24 at 12:45 PM, an observation was made of Resident # 22 eating lunch at bed. On the tray there was a sandwich split in half, a drink, a mixed fruit bowl, and a closed container. Surveyor verified with Care Assistant (CA) passing out trays that item in container was the resident's ice cream. On 9/5/24 at 1:08 PM, Resident #22 was observed sleeping with meal tray on table in front of them. On meal tray there is an uncut sandwich with 3 bite sized cuts, the container on tray was still unopened, and the fruit cup was still full. On 9/6/24 at 2:15 PM, Resident #22's care plan was…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-06 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of records and interview with facility staff, it was determined that the facility failed to ensure that staff reported suspected abuse to the administration in a timely manner resulting in the alleged perpetrator being allowed to continue to provide services to the victim prior to the initiation of the investigation. This was evident for 1(Resident #28) out of 8 residents reviewed for abuse during the recertification survey. The findings include: On 08/27/2024 at 02:24 PM, review of intake MD00206735 was started and revealed clinical notes written by LPN #22 on 6/14/2024 with an effective date of 6/8/2024 at 11:30 AM. The note stated that Resident #28 informed License Practical Nurse (LPN) #22 that he/she was going to report to someone that he/she was mishandled during care by the day shift Care Associate (CA) #42. LPN #22 told Resident #28 to stay on the unit for physical assessment for injuries and called the supervisor, RN #45 afterward. At 12:00 PM of same day, RN #45 interviewed the resident about the suspected abuse incident. On 06/08/2204 at 4:00PM, RN #45…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-06 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interviews it was determined that the facility staff failed to follow professional nursing standards as evidenced by nursing staff failure to sign the medication record after an antibiotic was administered. This deficient practice was evident in 1 (#123) of 2 medical records reviewed for medication administration during the survey. The findings include: On 09/05/24 at 3:13 pm the surveyor reviewed notes in the electronic medical record (EMR) which revealed Resident #123 was ordered antibiotic therapy, but the medication was not available. An alternative antibiotic was ordered and given by Nurse #70 per nursing note. Further review of the medication record revealed the antibiotic was not signed off as given by Nurse #70 on the medication record. On 09/06/24 at 11:30 am during an interview with Assistant Director of Nursing RN #9 who verbalized the nurses are supposed to sign the medication record after medications are given. On 09/06/24 at 12:37 pm During an interview with RN #5 the surveyor asked what the expectation of the nursing staff after…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-06 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview it was determined that the facility staff failed to administer antibiotic therapy as ordered for a resident. This deficient practice was evident in 1 (#123) of 2 resident records reviewed for medication administration during the survey. The findings include: On 09/05/24 at 2:35 pm the surveyor reviewed Resident #123 which revealed the resident was admitted to the facility on [DATE] with a known infection of the right prosthetic hip and ordered to receive antibiotic therapy Cefazolin 2 grams intravenously (IV) every 8 hours for 6 weeks. Review of the medication administration record revealed Resident #123's first dose of antibiotic therapy was due on 08/03/22 at 10:00 pm and the antibiotic was not given. Nurse #78 wrote a note on 08/04/22 at 2:48 am indicating the prescribed IV antibiotic was not available, but an alternative antibiotic was ordered and available in the Omnicell medication dispensing machine. Nurse #70 wrote a note on 08/04/22 at 7:16 am indicating the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-06 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview it was determined the facility staff failed to provide documentation to verify a resident received a shower during their admission. This deficient practice was evident in 1 (#123) of 1 resident record reviewed for showers during the survey. The findings include: On 09/05/24 at 2:54 pm during an interview with the Director of Nursing #8 who verbalized normally a shower/skin sheet must be completed. Additionally, the Geriatric Nursing Assistants gives the resident a shower and the assigned nurse must go assess the resident's skin. The nurse completes the skin sheet and there is a place on the form where they can document a shower was given. A copy of the form was requested for Resident #123 for documentation they received a shower. On 09/05/24 at 4:39 pm during an interview with Administrator #1 they verbalized the resident's skin sheets are not a part of the medical record. There was no documentation to verify Resident #123 received a shower.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-11 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation and staff interview it was determined that the facility staff failed to ensure residents were fed at the same time. This was evident for 2 out of 4 dining observations. The evidence includes: This surveyor observed dining on the Cottonwood unit on 10/3/19. Residents seated at tables #13 and #17 (the tables were butted up against each other) were observed eating at 11:48 AM while Residents # 7 and # 102 were seated and waiting for their food. Resident # 102 was served at 11:59 AM and Resident # 7 was served at 12:05 PM. This surveyor observed dining on the Cottonwood unit on 10/04/19. Two residents were observed at tables # 13 and #17 eating at 11:55 AM. Residents # 102 and Resident # 7 were observed seated waiting for their food and not served their lunch until 12:03 PM. The Administrator and Director of Nursing were interviewed on 10/10/19 at 8:52 AM. They said they understood the findings and are addressing it.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-11 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on surveyor observation it was determined that the facility failed to provide a safe, clean, comfortable and homelike environment. This was evident for 1 bathing room and 1 hallway in the facility. The findings include: On 10/3/2019 at 9:43 AM during an initial tour of the facility, the Bathing Room across from Room N315 in Cardinal Cove was observed with a torn screen window. The tear was approximately 2 inches tall and 11 inches long. At 12:21 PM a missing piece of cove molding was observed on the 3rd floor outside the Meeting Room towards the Cardinal Cove doors. These Administrator and Director of Nursing were made aware of these findings during the exit conference on 10/10/2019.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-11 · tag F0623 — isolated
    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on medical record review and interview, it was determined the facility staff failed to notify the resident or responsible party in writing of the reason for Resident (#152) transfer to the hospital. This was evident for 1 of 2 resident reviewed for hospitalization during the annual recertification survey and 1 out of 71 residents selected for review during the survey process. The findings include: Review of medical record for Resident #152 revealed the resident was transferred to an acute care facility on 7/15/19. Further record review and interview with the Director of Nursing and Administration on 10/9/19 at 12:00 PM revealed there was no documentation found in the medical record that the resident, and or the resident's responsible party was given written notice in a language and manner that they understood for the reason for the transfer of Resident #152. Interview with the Director of Nursing on 10/11/19 at 1:30 PM confirmed the facility staff failed to provide Resident #152 or the responsible party in writing the reason for Resident #152's transfer to the hospital.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-11 · tag F0641 — isolated
    Ensure each resident receives an accurate assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview it was determined the facility staff failed to document accurate assessment for Resident (#20) on the MDS. This was evident for 1 of 1 resident selected for review of restraints and 1 of 71 residents selected for review of MDSs assessment during the annual survey process. The MDS is a federally mandated assessment tool that helps nursing home staff gathers 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. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-11 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on clinical record review and staff interview it was determined that the facility staff failed to immediately place oxygen on a resident who needed it. This was evident for 1 out of 2 residents reviewed as part of the complaint process. The findings include: Resident #453's clinical record was reviewed as part of an investigation into an alleged delay in the treatment of the resident's condition. A review of the clinical record revealed that on 10/20/18 at 1:39 AM the resident was noted to have an oxygen level of 94% on room air. The resident's oxygen level dropped to 91% on 10/21/18. In response the nurse called the physician who then ordered for the resident to receive oxygen at 2 Liters via nasal cannula. The resident is placed on oxygen and then is sent to the hospital per family wishes. The Administrator and Director of Nursing (DON) were interviewed on 10/11/19 at 9:20 AM. The DON said she would expect the nurse to use nursing judgement to start O2 at 2L and call physician to ask if is this appropriate. The DON was interviewed on 10/11/19 at 10:08 AM. She stated that the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-10-11 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, it was determined the facility staff failed to obtain weights as ordered for Resident (#152). This was evident for 1 of 71 residents selected for review during the survey process. Medical record review for Resident #152 revealed on 7/1/19 the physician ordered: weight daily x3 days and then 3 times a week for acute CHF diagnosis. Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping power of the heart muscles. While often referred to simply as heart failure, CHF specifically refers to the stage in which fluid builds up around the heart and causes it to pump inefficiently. An early warning sign that the CHF is getting worse is fluid and water retention evidenced by sudden or steady gain in daily weight (for example, 2 to 3 pounds in 24 hours or 5 pounds over a couple of weeks) shows that the body is retaining fluid. Further record review revealed the facility staff failed to obtain weights on 7/3/19 and 7/5/19. Interview with the Director of Nursing on 10/11/19 at 1:30 PM confirmed 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-10-11 · tag F0925 — failed to control pests — isolated
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation it was determined that the facility failed to maintain an effective pest control program as evidenced by the presence of a mouse. This deficient practice has the potential to affect all residents. The findings include: On 10/4/2019 at 7:56 AM while inspecting medical records, a mouse was observed in the Cardinal Cove Activities Room running across the room from under the refrigerator to under a chest of drawers opposite the refrigerator. At 8:00 AM a mouse was observed in the same room running along the wall from behind the refrigerator to underneath the white heating units on the perimeter of the room. Review of the facility's pest control logs confirmed mouse sightings within the facility. The Administrator and Director of Nursing were made aware of these findings during the exit conference on 10/10/2019.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-10-11 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation On 10-3-19 during the annual recertification survey it was determined the facility failed to post the required nursing staffing data in a readily accessible area for residents and visitors at any given time. This was evident on 1 out of 4 nursing assignment boards The findings include: On 10-3-19 the nursing assignment board on the Cottonwood Corner Nursing Unit was located, after staff inquiry, behind the reception desk on a wall. To read the staffing board this surveyor had to walk around and behind the reception desk. The concern that the staffing board which list the staff names, their position and room assignments was not readily available to residents and visitors was discussed with the Unit Manger on 10-3-19 at 12:20 AM and the facility Administrator on 10-4-19 at 8:30 AM.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction

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

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

Fines & penalties

$49,725 in federal fines across 1 penalty.

  • $49,725 — penalty dated 2024-09-06

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ERICKSON SENIOR LIVING — 17 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 →

RatingThis homeChain avg
Overall 4 of 54.2-0.2 vs chain
Health inspection 4 of 53.6+0.4 vs chain
Staffing 4 of 54.8-0.8 vs chain
Quality measures 4 of 54.1≈ chain avg
The other 16 homes this chain runs (chain average 4.2★, 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 / managerTypeRoleShareSince
NATIONAL SENIOR COMMUNITIES, INCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF100%since 01/14/2021
BROWN, IANIndividualCORPORATE DIRECTORsince 04/01/2023
BROWN, PATRICIAIndividualCORPORATE DIRECTORsince 04/01/2022
CLUPPER, KATHERINEIndividualCORPORATE DIRECTORsince 04/01/2024
COLINS, MARYIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 04/01/2018
ELWOOD, RICHARDIndividualCORPORATE DIRECTORsince 04/01/2025
ERSTAD, EILEENIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 02/15/2007
JACQUE, ZINAIndividualCORPORATE DIRECTORsince 04/01/2018
LEONARD, MONTYIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 04/01/2022
MOSCATO, MARYIndividualCORPORATE DIRECTORsince 04/01/2024
PAULK, PAMELAIndividualCORPORATE DIRECTORsince 04/01/2022
POMERANZ, WILLIAMIndividualCORPORATE DIRECTORsince 04/01/2025
REEL, STEPHANIEIndividualCORPORATE DIRECTOR; CORPORATE OFFICERsince 04/22/2013
ROSKIEWICZ, MICHAELIndividualCORPORATE DIRECTORsince 04/01/2019
SHARP, RUSSELIndividualCORPORATE DIRECTORsince 04/01/2023
WALLICK, DANIELIndividualCORPORATE DIRECTORsince 04/01/2025
EMBLEY, MARKIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/27/2021
GANTERT, NEALIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2018
HALL, JOHNIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/30/2010
SAWICKI, SCOTTIndividualCORPORATE OFFICERsince 04/01/2024
STINER, PAMELAIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 04/01/2024
TYLER, DANIELIndividualCORPORATE OFFICERsince 04/01/2025
ERICKSON SENIOR LIVING LLCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 02/12/2025
BUTLER, RICHARDIndividualOPERATIONAL/MANAGERIAL CONTROLsince 01/01/2014
JEFFREYS, RONALDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/11/2025
SWEETSER, CHRISTIANIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 03/01/2022
WOLF, JUSTINIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 09/17/2023
BISON, MICHAELIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 10/14/2025
RIDLEY, FREDIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 10/14/2025
SONES, RANDALLIndividualINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFsince 10/14/2025

CMS files one row per role, so the 48 rows in the source record cover these 30 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$19.1M
Net patient revenuemost recent cost report
Operating marginrevenue minus expenses
$10.5M
Related-party expense9% of expenses
Who pays — share of resident-days
Medicaid 16%Medicare 21%Other / private 62%

This home reported $10.5M 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

$2,662per resident / day
operating cost
$80,920per month
≈ monthly operating cost
$453per day
avg. revenue, all payers

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

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215308. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-12, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

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

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

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