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Wicomico Nursing Home

900 Booth Street, Salisbury, MD 21801 · Government - County · 102 certified beds · (410) 742-8896 Medicare & Medicaid certified

Call the home — (410) 742-8896 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citation on record (F0600) — cited Jun 20194 actual-harm citations$28,343 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)
  • lower-than-typical staff turnover (26% vs 45% nationally) — better care continuity
Worth asking about
  • it has an abuse, neglect, or exploitation citation (F0600), cited Jun 2019
  • it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0604, F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • it has 4 actual-harm citations
  • a high number of inspection citations overall (40) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $28,343 in federal fines (most recent 2024-08-29)

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 3 of 5

Location & what’s nearby

Hospital
★★★★ 4/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
1205 Pemberton Dr · (410) 341-0300 · Call to confirm hours
Pharmacy
803 West Rd · (443) 736-4662 · Call to confirm hours
Grocery
811 West Rd · (410) 546-9144 · Call to confirm hours
Park
Manoa Blvd · Typically dawn to dusk
Place of worship
Mineola Avenue &, Powhatan Blvd · (410) 546-5047

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 2 of 5
Short-stay residentsrehab / post-hospital 3 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 3 to 4 stars. From monthly CMS archive snapshots.

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

Overall rating4★
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 increased27.3%20.4%15.4%worse
Long-stay residents who lose too much weight6.8%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder5.1%0.5%0.9%worse
Long-stay residents with a urinary tract infection3.3%1.5%2.0%worse
Long-stay residents with depressive symptoms0.6%22.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury2.7%2.4%3.3%better
Long-stay residents whose ability to walk worsened34.4%22.2%16.1%worse
Long-stay residents on antianxiety or hypnotic medication25.7%16.7%18.9%worse
Long-stay residents given the seasonal flu vaccine98.3%96.6%95.3%typical
Long-stay residents with pressure ulcers3.0%5.9%4.7%better
Long-stay residents with worsening bladder/bowel control23.3%25.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table12.8%13.8%17.1%better
Short-stay residents who newly got an antipsychotic medication1.7%1.1%1.4%worse
Short-stay residents given the seasonal flu vaccine87.2%80.6%79.4%typical
Short-stay residents rehospitalized after admission14.1%21.0%22.6%better
Short-stay residents with an outpatient ER visit15.3%9.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days1.211.331.67better
Long-stay outpatient ER visits per 1,000 resident days1.191.201.80better

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.

51.3% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 124 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

51.3%U.S. median 51.5%
Got home and stayed home
8.8%U.S. median 10.7%
Went back to hospital
56.5%U.S. median 56.6%
Met the expected recovery
0.45U.S. median 0.31
Therapy hours / resident / day
0.16hours / resident / day
Physical therapy
0.22hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 56.5% 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 69 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 0.45 therapist hours per resident per day in 2026Q1 — more than 75% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 11% 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 SNF51.3%CMS range 42.1–61.451.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF8.8%CMS range 5.8–12.910.7%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 discharge56.5%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 discharge59.4%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 discharge46.4%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 identified96.3%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care settingnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge90.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.5%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.8%CMS range 3.2–10.07.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.791.02Oct 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

0.85
RN hours/ resident / day
0.36
LPN hours/ resident / day
2.55
Aide hours/ resident / day
3.76
Total nurse hours/ resident / day
0.44
RN hoursweekends
25.9%
Total nursing turnover
28.6%
RN turnover

How full it usually is: this home is certified for 102 beds and averages 65.6 residents a day — about 64% occupied, or roughly 36 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.76 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.85 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 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 3.28 hrs/resident/day on weekends vs 3.95 on weekdays — 17% thinner on weekends. RN hours go from 1.01 to 0.44 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 26% 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

4
deficiencies at the latest standard inspection (2026-02-05)
4
at the previous standard inspection (2024-08-29)

Deficiencies are unchanged from the previous inspection. 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.

40 citations, most serious first. The 14 most serious are shown; the remaining 26 are one tap away and print in full.

  • Actual harm · Gcited before2024-08-29 · 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 a review of a facility reported incident, medical record review, facility documentation review, observation and staff interviews, it was determined the facility failed to keep a dependent resident free from injury while transporting to activities in a wheelchair, which resulted in actual harm to Resident (R) #28. The failure of facility staff to place leg rests on a wheelchair while transporting a resident resulted in a fracture in the lower leg. This was evident for 1 of 30 sampled residents. The facility failed to ensure a resident was free from accident hazards by not identifying new fall interventions for one of three residents (R51) reviewed for falls resulting in a head laceration and pubic fracture. The facility failed to provide leg rests for the residents identified as requiring leg rests for injury prevention for one of one residents (R57) reviewed for wheelchair safety of 30 sampled residents. The findings include: 1. On 8/26/24 at 2:22 PM facility reported incident MD00194543 was reviewed…

    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 · G2024-08-29 · tag F0791 — failed to provide routine dental services — isolated
    Provide or obtain dental services for each 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 observations, resident and staff interviews, and record review, the facility failed to ensure routine and 24-hour emergency dental care was provided or obtained from an outside resource to meet the needs for one of one resident (Resident (R) 55) reviewed for dental care out of 30 sampled residents resulting in significant weight loss. The facility failed to provide prompt dental services to a resident with identified dental pain by ensuring dental services were properly and timely arranged and completed to ensure continuity of care was provided to the resident. Findings include: Review of R55's Face Sheet located in the resident's electronic medical record (EMR) Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses that included left and right hip contracture, right knee contracture, congestive heart failure, and adjustment disorder with anxiety. Review of R55's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/24 located in the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2019-06-13 · 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

    Based on resident interview, staff interview, clinical record review, and a review of the facility abuse investigation it was determined that the facility staff failed to ensure residents were free from abuse (#36). This was evident for 1 out of 2 residents reviewed for a reportable incident. The findings include: A review of Resident #36's clinical record and the facility investigation revealed that the resident alleged to the Assistant Director of Nursing (ADON) and to the Administrator that geriatric nursing assistant (GNA) #23 had used a dry towel to apply lotion to his/her face and nose. The resident complained during the facility investigation that the towel was rough, and it hurt. The resident further informed the facility during their investigation that GNA #23 then shoved the towel in the resident's mouth. The resident was quoted during the facility investigation stating: He hurt me. I thought a tooth had broke. A review of the facility clinical record revealed that the resident was assessed. A review of a nursing note written on 4/18/19 noted: Redness and scratch marks…

    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 · Gcited before2019-06-13 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on a facility reported incident, review of a medical record, and staff interview, it was determined that a facility staff member failed to follow a resident's care plan to prevent the resident from sustaining a laceration to the leg which required laceration repair. This occurred for 1 (Resident #50) of 8 residents reviewed for accidents during an annual recertification survey. The findings include: Review of facility reported incident MD00134122 on 06/10/19 revealed an allegation Resident #50 sustained a laceration to the right lower leg during a transfer on 11/25/18. Review of Resident #50's medical record on 06/10/19 revealed Resident #50 had a history of a right fractured femur and was totally dependent upon staff for all of his/her care. Resident #50 was also noted to be at risk for non-pressure related skin impairment (skin tears) related to poor safety awareness. On 11/01/18 at 8:10 AM, Resident #50 suffered a skin tear to the right lower leg while being transferred from the bed to his/her wheel chair. Resident #50's injury was cleansed with normal saline and steri…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-05 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interviews, it was determined that the facility failed to ensure that care and treatment decisions for a resident assessed to lack decision-making capacity were made by a legally authorized representative. This was evident for 1 (Resident #7) of 5 residents reviewed for advance directives during the annual survey. The findings include: On 02/02/2026 at 12:31 PM, a review of Resident #7's medical record revealed two signed Physician Certifications Related to Medical Conditions, Decision Making, and Treatment Limitations, which documented that the resident lacked adequate decision making capacity. However, there was no evidence in the medical record of a legally authorized representative to make decisions for the resident. On 02/03/2026 at 11:00 AM, during an interview, the Social Work Director confirmed that Resident #7 had two certifications of incapacity and stated that, because the resident's children were not involved, the resident's sister had been making decisions for the resident. The Social Work Director further stated that the facility did…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-05 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, record reviews, and observations it was determined that the facility failed to ensure that residents requiring assistance with turning and repositioning were turned and repositioned at least every two hours. This was evident for 2 (Resident #3 and #4) out of 2 residents observed for pressure ulcers during the annual survey. The findings include: 1) On 02/02/2026 at 11:56 AM, record review revealed that Resident #3 had an order to be turned and repositioned every two hours. On 02/04/2026 at 9:11 AM, an observation revealed that Resident #3 was lying on his/her back. On 02/04/2026 at 11:23 AM, an observation revealed that Resident #3 was lying on his/her back. On 02/04/2026 at 1:17 PM, record review revealed that the resident had been signed off that they were turned and repositioned. On 02/04/2026 at 1:20 PM, an interview with a Registered Nurse (Staff #11) revealed that the expectation was that residents who required the assistance should be turned and repositioned every two hours. On 02/04/2026 at 1:23 PM, an observation revealed that Resident #3 was lying 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-05 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, it was determined that the facility failed to discard expired medications and store medications properly. This was evident for 2 out of 3 medications carts observed as part of the medication storage task during the annual survey. The findings include:On 02/05/2026 at 9:49 AM, an observation of medication cart in the 100s unit was conducted by the surveyor and Staff #7. The surveyor observed 1 bottle of Aspirin 325mg with an expiration date of 12/2025.A brief interview was conducted with Staff #7. When asked who is responsible for ensuring expired medications are not in the medication cart, she replied that the cart belonged to nurses and therefore nurses were supposed to check for expired medications every shift.On 02/05/2026 at 10:11 AM, another medication cart was observed in the 500s unit. The observation was conducted by the Surveyor and Staff #15.The medication cart contained the following expired medications:1). A bottle of Aspirin 325 mg that had an expiration date of 12/2024.2). A bottle of Tylenol extra strength with an expiration date…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-05 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interviews, it was determined that the facility failed to use appropriate infection control practices while handling laundry. This was evident during the observation of the laundry room as part of the infection control task during the annual survey.The findings include:Personal Protective Equipment (PPE) refers to specialized clothing and gear-gloves, gowns, masks, and face shields designed to protect workers and patients from infectious materials, contaminants, and bloodborne pathogens. It acts as a physical barrier, critical for infection control during procedures and in high-risk environments.On 02/04/2026 at 12:45 PM, a tour of the laundry room was conducted. In the dirty laundry room area, the Surveyor observed a laundry cart half-way filled with clothes that were not bagged. There was a cart near the wall that had 2 hospital gowns and gloves.A brief interview was conducted with Staff #2. When Staff #2 was asked if the clothes were dirty, she said yes and that the clothes belonged to different residents in the facility. She also stated that she needed…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-03-10 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor reviews of a facility reported incident and facility staff interview, it was determined that the facility failed to report the final investigation of an incident of alleged abuse reported by a resident's family member to the Office of Health Care Quality. This finding was evident for 1 (Resident #3) of 4 residents reviewed during a complaint survey. This finding is related to the facility reported incident #MD00212903. The findings include: On 03/06/2025, an on-site review of the facility reported incident for Resident #3 revealed that, on 12/19/24, Resident #3 was observed by a staff member and the resident's family member with discoloration to her bilateral hands and left forearm. Resident #3 was unable to describe how the discoloration happened. Further review of the facility investigation revealed that the facility submitted the initial report to OHCQ (Office of Health Care Quality) on 12/19/24, within 24 hours of the allegation as required. However, the final investigation report was not submitted to OHCQ. The facility is required to complete the investigation…

    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 · D2025-03-10 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on reviews of a complaint, interviews with staff, and reviews of a closed record, it was determined that the facility failed to ensure that a resident's medications were administered as ordered. This was evident for 1 (Resident #1) of 4 residents reviewed during a complaint survey. The findings include: Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication errors and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles. Review of complaint MD00215237 on 03/06/25 revealed an…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-03-10 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and staff interview, it was determined the facility staff failed to maintain a medical record in the most accurate form. This was evident for 1 of (Resident #1) of 4 residents reviewed during a complaint survey in relation to advanced directives. The findings include: A medical record is the official documentation for a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. resident records. A review of Resident #1's closed medical record revealed a completed physician certification related to medical condition, decision making, and treatment limitations form dated 03/29/24. The facility nurse practitioner completed the form, signed the form, that was found in Resident #1's closed medical record on 03/06/25. In an interview with the facility CRNP#1 on 03/06/25 at 5:23 PM, CRNP#1 stated that she did not know why the signed certification form found in Resident #1's…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-08-29 · tag F0657 — failed to keep the care plan current — pattern
    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 record review, observation, and staff interview it was determined that facility staff 1) failed to update care plans when there were changes in resident needs or preferences and 2) failed to thoroughly evaluate and revise resident plans of care after each assessment. This was evident for 6 (#40, #27, #34, #28, #504, #505) of 10 residents reviewed during a complaint survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. 1) On 8/26/24 at 10:00 AM Resident #40's medical record was reviewed and revealed an August 2024 physician's order for, Geri sleeves to bilat arms at all times. May remove for care, then reapply, every shift for skin discoloration. Geri-sleeves protect the upper extremities from abrasions, bruises, snags, and skin tears. Review of Resident #40's care plan, has potential for impairment to skin integrity r/t fragile skin, urinary incontinence, impaired mobility had 5 interventions. The care plan was not updated to reflect the use 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-29 · 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

    Based on observations, interviews, and policy review, the facility failed to provide visual privacy during a bed bath for one of one resident (Resident (R) 56) reviewed for privacy of 30 sample residents. This failure increased the risk of residents feeling humiliated and embarrassed when being exposed to others during care. Findings include: Review of the Code of Maryland Regulations, dated 09/18/19 and provided as the facility's residents' rights policy, revealed A nursing facility shall provide care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect, and in full recognition of the resident's individuality .personal privacy in personal care . Review of the Bed Bath procedure, dated 04/01/90, revealed Screen patient [pull curtains] .Remove clothing and cover with sheet, not exposing patient unnecessarily . Review of R56's electronic medical record (EMR) quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/02/24 revealed R56 was totally dependent on staff for bathing and R56 had a Brief Interview…

    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 · D2024-08-29 · tag F0604 — failed to not use physical restraints improperly — isolated
    Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
    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 observations, interviews, record review, and policy review, the facility failed to maintain a restraint free environment for one of one resident (Resident (R) 51) reviewed for physical restraints out of 30 sample residents. This failure increased the potential for R51, if attempted, to not be able to leave her bed. The use of restraints increased the risk of negative outcomes such as decline in physical functioning, increased accident hazards and falls, a loss of autonomy, and increased withdrawal, depression, and/or reduced social contact. Findings include: Review of the Code of Maryland Regulations, dated 09/18/19 and provided as the facility's residents' rights policy, revealed a physical restraint means a device including material or equipment, attached or adjacent to a resident's body, that the resident cannot remove easily and that restricts the resident's freedom of movement .Physical restraints may be used only: as an integral part of the an individual medical treatment plan; if absolutely…

    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
Show the remaining 26 citations
  • Potential for harm · Dcited before2024-08-29 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview it was determined the facility failed to report allegations of an injury of unknown source within 2 hours of the discovery of possible abuse to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 2 (#24, #501) of 10 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 8/26/24 at 9:22 AM a review of facility reported incident MD00204622 revealed Resident #24 was noted to have a discoloration/bruise to the outer corner of the right eye on 4/11/24, which was a Thursday. Review of the facility's investigative packet revealed the discovery was on 4/11/24 at 10:40 AM. Also reviewed was an email confirmation that the initial report was sent to OHCQ on 4/11/24 at 5:05 PM, which was not within 2 hours of the discovery. Additionally, a 4/11/24 at 5:07 PM note written by the Director of Nursing (DON) documented, received a call back from [name of Resident #24's daughter]. This writer informed her that it had been reported that resident has a yellowish green discoloration to corner 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-29 · 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 facility administrative records, facility investigations, and staff interview, it was determined the facility failed to thoroughly investigate incidents of injuries of unknown origin. This was evident for 2 (#24, #505) of 10 facility reported incidents reviewed during a complaint survey. The findings include: 1) On 8/26/24 at 9:22 AM a review of facility reported incident MD00204622 revealed Resident #24 was noted to have a discoloration to the outer corner of the right eye on 4/11/24, which was a Thursday. Resident #24's daughter was informed of the injury and stated that she noticed redness to the sclera and the discoloration to the right eye on 4/7/24, which was a Sunday. Review of the facility's investigative packet included a master list of residents that were interviewed asking if they felt safe in their room, a statement from the house supervisor, and statements from (8) staff members that had worked on that unit. There were (10) additional staff members that had worked from Sunday to Thursday that had not been interviewed. No one reported a discoloration…

    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 · D2024-08-29 · 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 ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (#504) of 10 residents reviewed for facility reported incidents during a complaint survey. The findings include: The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident. On 8/27/24 at 7:55 AM Resident #504's medical record was reviewed and revealed on 6/1/23 at 10:05 PM, Resident #504 was, standing at room door and void[ed] out into the hallway, hollered at staff w/redirection. On 6/3/23 at 12:40 PM it was documented, sometimes combative and angry and exit seeking. On 6/6/23 at 10:26 AM a Social Service Note 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-29 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and policy review, CPAP (continues positive airway pressure)/ nebulizer masks were not properly stored for two of two residents (R5 and R26) reviewed for respiratory care out of 30 sample residents. The failure to properly store CPAP and nebulizer masks increased the potential for respiratory infections. Findings include: Review of R5's undated Face Sheet located under the Profile tab of the EMR revealed the resident was admitted on [DATE]. Diagnoses included asthma. Review of R5's annual MDS with an ARD of 05/10/24 revealed the facility assessed the resident to have a BIMS score of 13 out of 15 which indicated the resident was cognitively intact. During observations on 08/26/24 at 10:36 AM, 08/27/24 at 9:42 AM and 08/28/24 at 2:33 PM, R5's CPAP-mask was lying on top of the dresser at the right side of the bed uncovered. Review of R26's undated Face Sheet located under the Profile tab of the EMR revealed the resident was admitted on [DATE]. Diagnoses included unspecified…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2019-06-13 · tag F0561 — failed to honor residents' choices — pattern
    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
    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 provide showers to Residents (#26 and #31). This was evident for 2 of 2 resident reviewed for choices during the annual survey process and 1 of 34 residents selected for review. The findings include: 1. The facility staff failed to provide showers to Resident #26. Surveyor interview with Resident #26 on 6/10/19 at 1:00 PM revealed the resident stating he/she did not receive showers. Review of facility Geriatric Nursing Assistant documentation revealed the facility staff failed to document a shower for the resident from 5/1/19 to 5/31/19 and no documented showers from 6/1/19-6/11/19. The resident is scheduled for showers on Friday 7-3 shift and Tuesday 3-11 shift. 2. The facility staff failed to provide showers to Resident #31. Medical record review revealed Resident #31 is to be showered on: Friday 7-3 shift and Tuesday 3-11. Further record review revealed the facility staff failed to provide/document shower for Resident #26 from 5/1/19 to 5/31/19 (except 5/7/19 and 5/28/19 on the evening…

    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 · Ecited before2019-06-13 · tag F0657 — failed to keep the care plan current — pattern
    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 staff interview and record review, it was determined that the facility failed to review and revise the care plans for Resident (#31) to reflect accurate and current interventions. The facility also failed to and prepare a comprehensive care plan with an interdisciplinary team. This was evident for all residents (3 of 34) reviewed during the complaint survey. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. Once the facility staff completes an in-depth assessment of the resident, the interdisciplinary team meet and develop care plans. Care plans provide direction for individualized care of the resident. A care plan flows from each resident's unique list of diagnoses and should be organized by the resident's specific needs. The care plan is a means of communicating and organizing the actions 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · 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, observation and interview, it was determined the facility staff failed to provide residents (#42, #53 and #164) with the most dignified existence. This was evident for 3 of 34 residents observed during the dining observation task of the annual survey. The findings include: 1. On 6-12-19 at 12:40 PM in the dining room Resident #42 was observed being fed. Resident #42 due to Alzheimer's disease is unable to feed her/himself and requires a pureed diet due to a swallowing problem. The person feeding Resident #42 took the 3 scoops of pureed food and using a spoon mixed the items together into one pile and started feeding the resident. This surveyor then got the Assistant Director of Nursing (ADON) who observed the practice and took corrective action. The person feeding Resident #42 was a private sitter hired by the family with unknown credentials. The ADON confirmed the undignified feeding practice on 6-12-19 at 12:45 PM. Cross reference F729 2. This surveyor observed on 06/10/19 from 1:08 PM to 1:15 PM a staff member wearing light purple scrubs feeding Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-06-13 · tag F0578 — failed to honor advance directives / code status — isolated
    Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, it was determined the facility staff failed to void an older MOLST form located in a resident's active medical record for Resident (#26). This was evident for 1 of 6 residents reviewed for Advance Directives during an annual recertification survey and 1 of 34 residents selected for review during the annual survey process. The findings include: The Maryland MOLST is a portable and enduring medical order form covering options for cardiopulmonary resuscitation and other life-sustaining treatments. The medical orders are based on a resident's or Power of Attorney (POA) wishes about medical treatments. The use of MOLST increases the likelihood that a resident's wishes regarding life-sustaining treatments are honored throughout the health care system. Do Not Resuscitate (DNR) is a legal order, written or oral depending on country, indicating that a person does not want to receive cardiopulmonary resuscitation (CPR) if that person's heart stops beating. Medical record review of Resident…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interviews with facility staff, it was determined the facility staff failed to notify the responsible party in a timely manner of a resident's fall ( Resident #212) in 1 of 1 records reviewed for neglect. The findings included: Resident #212 was admitted to the facility with a diagnosis of dementia and determined by 2 physicians to be incapable of making medical and financial decisions. An alarm was placed on Resident #212's chair and bed to notify the facility staff if the resident tried to get out of the chair or bed because Resident #212 had poor safety awareness. On 1-9-19 at 3:55 AM Resident #212 was found on the floor in her/his room sitting upright in front of the bathroom door. The bed alarm previously functioning was found by the Maintenance Director on 1-9-19 to be non-functioning per interview on 6-12-19 at 11:00 AM. The facility staff notified Resident #212's family on 1-9-19 at 8:10 AM approximately 4 hours after the fall resulting in the family being concerned over the delay in notification. On 6-12-19 at 12:00 PM the Assistant…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations it was determined the facility failed to 1) provide housekeeping and maintenance services to keep the residents' environment clean and in good repair, and 2) to protect the loss of a resident's denture. The environmental observations were evident on the 500 and 600 nursing units. The facility failed to protect the loss of Resident #50's denture. The findings include: 1) On 06/11/19 at 1:32 PM the following areas of concern were observed: In room [ROOM NUMBER] - 1, the bed side cabinets were observed in disrepair. In room [ROOM NUMBER] - 2, the resident's bed side commode had not been emptied and the window blinds were in disrepair. In room [ROOM NUMBER] - 2, the resident's bed side commode had not been emptied, the television remote was in disrepair, and the window blinds were also in disrepair, and an oxygen tank was not secured in a travel holder. On 06/11/19 at 1:32 PM, Resident #8's Geri chair was observed with frayed wires hanging out of the back. In an interview with staff member #6…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-06-13 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record review, staff interview, and a review of the facility investigation it was determined that the facility staff failed to conduct a thorough investigation. This was evident for 1 out of the 2 facility reported incidents reviewed. The findings include: A review of the investigation for the alleged abuse revealed that only the resident and the alleged perpetrator were interviewed. Other residents who could have been either abused as well or potentially aware of abuse were not interviewed. Staff members who worked on the unit were not interviewed to assist in substantiating the abuse or to ensure there were no suspicions of other residents being abused. Refer to F600. The Administrator was informed of the findings at the exit conference.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · 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 with staff it was determined the facility staff failed to provide a written notice for emergency transfers to the resident /or the resident representative. This was found to be evident for 1 out of 1 resident reviewed for hospitalization and 1 out of 34 residents selected for review during the annual survey. The findings include: Medical record review for Resident #45 revealed the resident was transferred to an acute care facility on 4/29/19 at 6:29 AM. There was no documentation found in the medical record that the resident or family was notified in writing of the transfer to the emergency department. In an interview with the acting Director of Nursing (DON) on 6/11/19 at 9:00 AM, the DON stated there is no documentation the resident nor the resident's family received notification of Resident #45's transfer to the hospital.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined the facility staff failed to provide the resident and their representative with a summary of the baseline care plan within 48 hours of admission to the facility. This was evident for 1 (Resident #263) of 34 residents reviewed during an annual recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #263's medical record on 6/12/19 revealed Resident #263 was admitted to the facility on [DATE]. Review of Resident #263's medical record failed to reveal documentation that a copy of the baseline care plan was provided to Resident #263 or Resident #263's responsible party within 48 hours after admission. In an interview with the facility Director of Nursing (DON) on 6/12/19 at 2:30 PM the DON stated that the facility does not give hard copies of the resident's care plan to either 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 · D2019-06-13 · tag F0656 — failed to write and follow a full care plan — isolated
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, it was determined the facility staff failed to initiate, provide and implement comprehensive care plans for residents. This was evident for 1 (Resident #1) of 34 residents selected for review during the annual survey process. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. On 6/13/19, a medical record review for Resident #1 revealed a diagnosis on 1/29/2019 of generalized anxiety disorder. Generalized anxiety is characterized by persistent and excessive feelings of worry or fear. It can cause nervousness, restlessness, trouble concentrating and may interfere with day to day routines. It was further noted that Resident #1's current care plan did not include interventions for anxiety. A nursing care plan contains all of the relevant information about a patient's diagnoses, the goals of treatment, the specific nursing orders (including what observations are needed and what actions must be performed), and a plan…

    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 · D2019-06-13 · 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 ensure Resident #26 was free from constipation. This was evident for 1 of 3 residents selected for review of constipation and 1 of 34 residents selected for review during the annual survey. The findings include: Medical record review and an interview with Resident #26 revealed the resident complained of constipation . The interview lead the surveyor to review the bowel movement documentation (Daily Care Flow Record) for the resident and the response or lack of response revealed the facility staff (Geriatric Nursing Assistants-GNA) failed to document that Resident #26 had a bowel movement 5/12/19-5/16/19 (5 days), 5/18/19-5/21/19 (4 days) and 6/6/19 to 6/9/19 (4 days) on all 3 shifts. Although the facility has a Bowel Protocol to address no bowels movements for 6 consecutive shifts (2 days), 9 consecutive shifts (3 days) and 12 consecutive shifts (4 days), there is no evidence the facility staff intervened when the GNAs documented that Resident #26 had not had a bowel movement for up to 5…

    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 · D2019-06-13 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such 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 medical review and interview, it was determined the facility staff failed to thoroughly address pain complaints for Resident (#45) and failed to consistently assess the effectiveness of pain relief when pain medication was administered to Resident (#45). This was evident for 1 of 4 residents reviewed for pain and 1 of 34 residents selected for review during the annual survey process. The findings include: Pain is a signal in your nervous system that something may be wrong. It is an unpleasant feeling, such as a prick, [NAME], sting, burn, or ache. Pain may be sharp or dull. It may come and go, or it may be constant. You may feel pain in one area of your body, such as your back, abdomen, chest, pelvis, or you may feel pain all over. 1 A. The facility staff failed to conduct a post pain assessment to ensure Resident #45 was pain free. Medical record review for Resident #45 revealed on 5/3/19 the physician ordered: Tylenol 630 milligrams, 2 tablets by mouth every 4 hours as needed for pain. Tylenol…

    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 · D2019-06-13 · tag F0729 — isolated
    Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, observation and interview, it was determined the facility staff failed to verify a privately hired sitter's training and competency to perform tasks as a Geriatric Nursing Aide (GNA) in the facility. This was evident for 1 of 1 residents (#42) selected for review of dignity care area during the annual survey process. The findings include: On 6-12-19 at 12:40 PM Sitter #21 was observed feeding Resident #42 in an undignified manner and it was confirmed with the Assistant Director of Nursing(ADON). When questioning the ADON about Sitter #21 on 6-12-19 she/he said the sitter had been hired by the family and had been with Resident #42 since admission. The ADON answered yes when asked if the sitter also bathed, dressed and transferred Resident #42 and acted as a GNA. On 6-12-19 at 1:28 PM the ADON stated the facility had not checked the qualifications or credentials of Sitter #21 to perform tasks as a GNA. The ADON then checked with the Maryland Board of Nursing and confirmed Sitter #21 was not a GNA. The facility failed to confirm the abilities of a…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, it was determined the facility staff failed to hold a blood pressure medication when the documented blood pressure was below the set parameter as ordered by the physician for Resident (#39). This was evident for 1 of 6 residents selected for un-necessary medication review and 1 of 34 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #39 revealed on 8/1/18 the physician ordered: Cozaar 25 milligrams by mouth, hold for systolic blood pressure (top number) less than 110 and on 10/18/18 the physician ordered: Metoprolol ER 25 milligrams by mouth every day for blood pressure, hold for systolic blood pressure (top number) less than 110. Cozaar is used to treat high blood pressure. Metoprolol is used alone or in combination with other medications to treat high blood pressure. Metoprolol is in a class of medications called beta blockers. It works by relaxing blood vessels and slowing heart rate to improve blood flow and decrease blood pressure. Review of the 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · tag F0770 — failed to provide lab services — isolated
    Provide timely, quality laboratory services/tests to meet the needs of residents.
    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 laboratory test as ordered for Resident (#31). This was evident for 1 of 34 residents selected for review of laboratory results in the survey sample. The findings include: Medical record review revealed on 9/27/18 the physician ordered: stool for OB (occult blood) annually due to diagnosis that included but not limited to anemia. Anemia is a condition in which you don't have enough healthy red blood cells to carry adequate oxygen to the body's tissues. The stool occult blood test is a lab test used to check stool samples for hidden (occult) blood. Interview with the acting Director of Nursing (DON) on 6/11/19 at 12:30 PM revealed the stools for occult blood are done in September and January and the stool for OB for Resident #31 should have been done in January 2019; however, there is no evidence the stool for OB was obtained as ordered. Interview with the acting DON on 6/13/19 at 1:30 PM confirmed the facility staff failed to obtain a stool for OB for Resident #31 as ordered 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · tag F0790 — failed to provide dental care — isolated
    Provide routine and 24-hour emergency dental care for each resident.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on clinical record review, resident observation, resident interview and staff interview it was determined that facility staff failed to obtain a dental examination for its residents (#53). This was evident for 1 out of 34 residents. The findings include: On 6/10/19 at 2:14 PM this surveyor was informed that Resident #53 told another surveyor that his/her teeth sometimes hurt and that the front, bottom teeth are broken and black. A review of the clinical record revealed that the resident did not make many complaints to the staff over the past year but there was also no evidence that a dental consult was obtained or even attempted. The Assistant Director of Nursing (ADON) was interviewed on 6/13/19 at 9:37 AM. The ADON confirmed that a dental exam has not been obtained for the past year.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · tag F0867 — failed to act on quality-improvement findings — isolated
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, it was determined the facility staff failed to thorough review during the QA meetings the continued use of antibiotics for Resident (#31). This was evident for 1 of 3 residents selected for review of Urinary Tract Infections and 1 of 34 residents selected for review during the annual survey process. The findings include: Quality Assurance (QA) and Performance Improvement (PI). QAPI takes a systematic, comprehensive, and data-driven approach to maintaining and improving safety and quality in nursing homes while involving all nursing home caregivers in practical and creative problem solving. QA is the specification of standards for quality of service and outcomes, and a process throughout the organization for assuring that care is maintained at acceptable levels in relation to those standards. QA is on-going, both anticipatory and retrospective in its efforts to identify how the organization is performing, including where and why facility performance is at risk or has failed to meet standards. A QAPI program must be ongoing and comprehensive,…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-06-13 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations and interview, it was determined the facility staff failed to promote an environment that decreased the potential of transmission of communicable diseases or infections for Residents (#34 and #163). This was evident for observation of meal delivery of breakfast on the 200 unit and 1 out of 34 residents selected for review of infection control during the survey process. The findings include: Surveyor observation of breakfast meal delivery on 6/11/19 at 9:00 AM revealed facility staff #12 delivered breakfast tray to resident #34. At that time, the Geriatric Nursing Assistant (GNA) used bare hands to apply jelly to the toast for Resident #34. Further observation revealed the GNA delivered breakfast to Resident #163. It was further observed at that time, the GNA used bare hands to spread jelly on the resident's toast. It was then observed, the facility staff applied 1/2 of the resident's fried egg and 1/2 off the scrapple to the bread, cut the bread in half; however, the facility staff used bare hands to make the sandwich. Interview with the acting Director 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · tag F0883 — failed to offer flu and pneumonia vaccines — isolated
    Develop 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 record review and staff interview it was determined the facility staff failed to address the pneumococcal vaccine with a Resident (#63). This was evident for 1 of 34 residents selected for review of infection control during the annual survey. Pneumonia is an infection in one or both lungs. Many germs, such as bacteria, viruses, and fungi, can cause pneumonia. You can also get pneumonia by inhaling a liquid or chemical. The pneumococcal vaccine is an active immunizing agent containing 14 types of Pneumococcus (the bacterial responsible for causing the infection of the lungs) that is associated with 80% of the cases of Pneumococcal pneumonia. Vaccination is the safest, most effective way to protect against pneumococcal disease. In healthcare settings, pneumococcal bacteria can be transmitted between healthcare workers and patients through direct contact with respiratory secretions. Efforts at preventing pneumococcal disease are a national health priority, particularly in older adults and especially in post-acute and long-term care settings Nursing facility licensure…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-13 · 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 — the official record, unedited, may be distressing

    Based on a review of employee records it was determined that a staff member was allowed to work prior to receiving abuse training. This was true for 1 out 1 employee reviewed for allegations of abuse. The findings include: A review of Staff #23's employee file revealed that the employee had a hire date of 7/7/18. Staff #23 did not receive abuse training until 9/22/18. The staff person worked almost 11 weeks without being trained on what constitutes abuse or how to report it. The Administrator was informed of the findings prior to exit.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-06-13 · tag F0732 — widespread
    Post nurse staffing information every day.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on surveyor observation and interview with staff it was determined that the facility failed to post the total number and the actual hours worked for Registered Nurses, Licensed Practical Nurses and Certified Nurse Aides. This was evident during an annual recertification survey. The findings include: During an observation of the facility on 06/11/19, the surveyor reviewed the nursing staff schedules. The surveyor was unable to locate a schedule that posted the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nurse aides. In an interview with the facility DON on 06/11/19 at 12:21 PM, the facility DON stated that the facility does not post the federal requirements for staffing only the staffing on the individual units are posted.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-06-13 · tag F0838 — failed to assess facility resources and resident needs — widespread
    Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on staff interview, it was determined that facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The findings include: In an interview with the facility administrator on 06/11/19 at 12:03 PM, the facility administrator stated that a facility assessment has not been completed. The facility administrator stated that s/he has only been the administrator of the facility for a few months.

    Administration 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

$28,343 in federal fines across 1 penalty.

  • $28,343 — penalty dated 2024-08-29

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.

Who owns this facility

Owner / managerTypeRoleSince
BOOTH, STACYIndividualOPERATIONAL/MANAGERIAL CONTROLsince 11/27/2020
LEONE-TINCHER, PATRICIAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 08/09/2021

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

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.

$9.2M
Net patient revenuemost recent cost report
-5.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 70%Medicare 11%Other / private 19%

About 70% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2024. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$388per resident / day
operating cost
$11,805per month
≈ monthly operating cost
$369per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2024). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MD

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215007. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-05, 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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