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Althea Woodland Nursing Home

1000 Daleview Drive, Silver Spring, MD 20901 · For profit - Limited Liability company · 50 certified beds · (301) 434-2646 Medicare & Medicaid certified

Call the home — (301) 434-2646 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

On the public record, this home looks stronger than most — but visit before you decide.

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)
  • no federal fines or payment denials on record
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (19% vs 45% nationally) — better care continuity
Worth asking about
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

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
★★ 2/5 CMS
Urgent care / clinic
831 University Blvd E · (301) 328-7155 · Call to confirm hours
Pharmacy
636 University Blvd E · (301) 439-6878 · Call to confirm hours
Grocery
8878 Piney Branch Rd · (240) 906-1419 · Call to confirm hours
Park
509 University Blvd E · (301) 495-2595 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

Overall quality measures 3 of 5
Long-stay residentspeople who live here 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 held steady at 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 increased23.0%20.4%15.4%worse
Long-stay residents who lose too much weight6.7%5.4%5.4%worse
Long-stay residents with a catheter left in their bladder0.6%0.5%0.9%better
Long-stay residents with a urinary tract infection3.5%1.5%2.0%worse
Long-stay residents with depressive symptoms1.2%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 injury2.3%2.4%3.3%better
Long-stay residents whose ability to walk worsened12.9%22.2%16.1%better
Long-stay residents on antianxiety or hypnotic medication13.3%16.7%18.9%better
Long-stay residents given the seasonal flu vaccine95.5%96.6%95.3%typical
Long-stay residents with pressure ulcers10.4%5.9%4.7%worse
Long-stay residents with worsening bladder/bowel control21.9%25.0%21.2%typical
Long-stay residents who got an antipsychotic medication — see the note below the table26.8%13.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.0%1.1%1.4%better
Long-stay hospitalizations per 1,000 resident days1.371.331.67better
Long-stay outpatient ER visits per 1,000 resident days0.931.201.80better

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.

37.1% 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 28 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

37.1%U.S. median 51.5%
Got home and stayed home
9.4%U.S. median 10.7%
Went back to hospital
0.42U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.19hours / resident / day
Occupational therapy
0.01hours / resident / day
Speech therapy

Therapy staffing: this home’s payroll records show 0.42 therapist hours per resident per day in 2026Q1 — more than 72% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 28% 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 SNF37.1%CMS range 22.6–53.551.5%Oct 2022–Sep 2024no different from U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.4%CMS range 6.0–14.810.7%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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identifiednot 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 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 dischargenot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF staynot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsenednot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalizationnot reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs1.391.02Oct 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

0.57
RN hours/ resident / day
0.82
LPN hours/ resident / day
2.31
Aide hours/ resident / day
3.70
Total nurse hours/ resident / day
0.46
RN hoursweekends
18.9%
Total nursing turnover
RN turnover

How full it usually is: this home is certified for 50 beds and averages 48.8 residents a day — about 98% occupied, or roughly 1 bed typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.70 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.31 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.38 hrs/resident/day on weekends vs 3.83 on weekdays — 12% thinner on weekends. RN hours go from 0.61 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 19% 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

13
deficiencies at the latest standard inspection (2025-04-25)
3
at the previous standard inspection (2021-04-09)

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

Inspection deficiencies

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

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.

30 citations, most serious first. The 10 most serious are shown; the remaining 20 are one tap away and print in full.

  • Potential for harm · D2026-06-23 · 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 observation and interview with facility staff, it was determined that the facility failed to ensure clean, safe, and comfortable environment. This was evident in 3 (Rooms 5, 26 and 27) of 4 rooms reviewed during the annual survey. The findings include: On 06/15/2026 at 1:11 PM, the surveyor toured the facility with the Maintenance Director and observed that there was no airflow in the bathroom of room [ROOM NUMBER]. The bathroom ambient air temperature felt warm, and an odor remained in the bathroom. During an interview, the Maintenance Director acknowledged that the exhaust fan was nonfunctional and confirmed that the unit would be repaired or replaced promptly. On 06/18/2026 at 9:43 AM, the surveyor observed the footboards for Beds A and B in room [ROOM NUMBER] were torn, chipped, cracked, and pitted. At 9:55 AM, the surveyor observed water-damage at the bottom of the closet doors in room [ROOM NUMBER]. The closet doors showed signs of swelling, warping, and bubbling paint. At 10:01 AM, the surveyor…

    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 no plan of correction
  • Potential for harm · E2025-04-25 · tag F0812 — failed to store, cook, and serve food safely — pattern
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to maintain proper sanitation for storage of food in the nursing units and in the kitchen. This was evident on 1 of 2 nursing units and on the initial tour of the kitchen during review of food storage and sanitation. The findings include: During the initial tour of the kitchen on 4/21/25 at 8:29 AM with the Food Services Director (FSD) and Staff #17 in attendance, the surveyor observed the following sanitation concerns: In Refrigerator #1, there was an opened half- gallon container of mustard, void of ¾ of its contents with a label 12/27/24 written in black on its cover. The label did not indicate when the item was opened and when the contents should have been used. The FSD stated the item was opened on 12/27/24 and should it have been discarded a long time ago. He immediately placed the item in the trash. Also, one half gallon container of chicken-base with opened on 4/15/25 which the FSD stated should have been discarded after 3 days of opening. In Refrigerator #2 was a white half gallon plastic…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2025-04-25 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 that the facility failed to maintain resident records completely and accurately. This was evident for 4 (Resident #15, #6, #34, #21) out of 16 sampled residents reviewed during the annual survey. 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. An advance directive is a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor. It is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity. Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0553 — failed to let residents help plan their care — isolated
    Allow resident to participate in the development and implementation of his or her person-centered plan of care.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interviews, it was determined that the facility failed to facilitate the inclusion of the resident and/or resident representative in care plan meetings. This was evident for 1 (Resident #21) out of 3 residents reviewed for care planning during the annual survey. The findings include: During an interview conducted on 04/23/25 at 02:25 PM, Resident #21's Resident Representative (RP) stated that he/she had not been informed about care plan meetings for Resident #21 in a while. On 04/23/25 02:37 PM, a review of Resident #21's clinical record revealed no evidence that care plan meetings were held for Resident #21 after 03/01/2023. On 04/24/2025 at 10:51 AM, an interview with the Director of Nursing stated that care plan meetings for residents are conducted quarterly and documented in the resident's medical record. During an interview conducted on 04/24/25 at 01:00 PM, the Social Services Director #6 confirmed that there were no care plan meeting notes documented in Resident #21's electronic medical record after 03/01/2023 but that she would look in…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · 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 facility staff interview and surveyor record review it was determined that the facility failed to document if Residents had an advance directive, wished to formulate an advance directive and were provided the educational information on advance directives. This finding was found to be evident in 2 out of 2 Residents (#16 & #31) reviewed for advance directives. The findings include: An advance directive is a legal document that specifies a person's wishes for end-of-life healthcare. It also specifies who should make healthcare decisions on your behalf if you are unable to do so yourself. On 04/22/2025 at 07:05 AM the surveyor conducted a record review of Resident #16's medical record. During this review it was revealed that Resident #16 or Resident's Representative was not asked if he/she had an advance directive, wished to formulate an advance directive or was provided the educational information on advance directives. There was a form in Resident #16's medical record titled Advance Directives Policy. This form was not completed by Resident #16 or Resident's Representative.…

    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 before2025-04-25 · 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 record review and interview, it was determined that the facility failed to implement and develop comprehensive care plans to address the residents' use of (1) anti-psychotic medications and (2) Anti-coagulant medications. This was evident in 2 (Resident #39 and #40) of 17 residents reviewed the development of comprehensive care plans during the 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. (1) Resident #39 was admitted to the facility with diagnoses which included Parkinson's disease, Dementia and Neurocognitive Disorder with Lewy Bodies. On 04/23/25 at 12:45 PM a review of Resident #39's clinical record revealed that the resident was receiving anti-psychotic medication, Quetiapine Fumarte 25mg daily at bedtime for Mood Disorder - start date 07/24/24 Further review of Resident #39's clinical record revealed that a care plan was not developed to monitor the resident's behaviors neither was a care plan developed to monitor…

    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 before2025-04-25 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, facility staff interview and surveyor record review it was determined that the facility failed to revise a Resident's care plan. This finding was found to be evident in 1 (Resident #31) out of 2 Residents reviewed for care plan timing and revision. The findings include: The surveyor conducted an initial tour of the facility on 04/21/2025 and observed Resident #31 in his/her room at 10:56 AM in bed with left lower extremity elevated and a heel protector boot to left lower extremity. A care plan is a written document that outlines the care to be provided to a Resident, tailored to their specific needs and goals. It's a document, evolving as the Resident's condition changes, allowing for ongoing assessment and modification of care. It's a guide detailing how to assess, diagnose, plan, implement and evaluate Resident's care. At 02:00 PM on 04/22/2025 the surveyor conducted a record review of Resident #31's medical record. Review of Resident #31's care plan revealed that Resident had a skin abrasion to his/her left great (big) toe on 01/10/2025. Further review of…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, it was determined that the facility failed to assess the nutritional needs of newly admitted residents in a timely manner. This was evident of 2 (Resident #42 and #10) of 17 residents reviewed for nutrition during the recertification survey. The findings include: Resident #42 was admitted to the facility on [DATE] with diagnoses which included Parkinson's Disease and Diabetes Mellitus On 04/22/25 at 10:00 AM a review of Resident #42's clinical record revealed that an initial nutritional assessment by the Registered Dietitian (RD) was not completed until 04/15/25, three months after the resident was admitted to the facility. An excerpt of the assessment is as follows: Weight loss trend noted. Cont to monitor weight, po intake, meds, labs and skin. Adjust recommendations as indicated per collaboration with IDT. If po intake declines or weight loss trend continues - offer oral nutrition supplement to optimize nutrition status. A further review of Resident #42's clinical record…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · 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

    Based on record review and interviews, it was determined that the facility failed to provide appropriate pain management for residents. This was evident for 1 (Resident #10) of 17 residents reviewed for pain during the recertification survey. The findings include: A pain scale is a tool used to help patients communicate the intensity of their pain to healthcare providers. It provides a standardized way to assess and track pain levels, enabling health care providers to better understand a patient's pain experience and adjust treatment plans accordingly. Numbers, generally 0-10 indicate the intensity of pain. Zero means no pain while 10 signifies severe pain. On 04/24/25 at 7:36 AM a review of Resident #10's clinical record revealed a physician's order dated 2/8/25 for Oxycodone HCL Oral solution 5Mg/5ml . Give 5ml via G-tube every 6 hours as needed for Pain and physician's order dated 11/18/24 for Acetaminophen 500mg. Give enterally every 8 hours as needed for pain not to exceed 3 grams in 24 hours. Further review failed to reveal a scale to determine at what pain level each…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · tag F0730 — isolated
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility staff interviews and employee record reviews it was determined that the facility failed to ensure that the required nurse aide performance reviews - 12 hour/year in-services were completed. This finding was found to be evident in 3 out of 3 employee personnel files (#10, #11 and #14) reviewed for annual required nurse aide performance review - 12 hour/year in-service. The findings include: On 04/24/2025 at 07:15 AM the surveyor conducted a record review of 3 nurse aide employee personnel files #10, 11 and 14. The record review revealed that the 3 employee personnel files did not contain current performance reviews - 12 hour/year in-services for the 3 nurse aides #10, 11 and 14. At 07:45 AM on 04/24/2025 the surveyor interviewed the Director of Nursing (DON). During the interview the surveyor conveyed to DON that the 3 nurse aides #10, #11 and #14 personnel files did not contain any current performance reviews - 12 hour/year in-services. The DON acknowledged that the 3 nurse aides #10, #11 and #14 did not have current performance reviews - 12 hour/year in-services…

    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
Show the remaining 20 citations
  • Potential for harm · D2025-04-25 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure a medication error rate of less than 5% for 1 (Resident #7) of 3 residents observed during the medication pass observation. This was evident for 3 medication errors out of 33 opportunities which resulted in an error rate of 9.09%. The findings include: PEG stands for percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach. PEG allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus. On 4/24/25 at 8:53 AM, the surveyor observation of medication pass for Resident #7 revealed that Licensed Practical Nurse (LPN) #15 administered all scheduled AM medications to the resident via PEG tube. The medications included ProSource Protein Oral Liquid 30ml (milliliters), half tablet of Oxycodone 5mg (milligrams) and 1 packet of Arginaid. On 04/24/25 at 8:44 AM, the surveyor reviewed Resident #7's clinical record. The review revealed that…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2025-04-25 · 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, facility staff interviews and surveyor record review it was determined that the facility failed to follow infection prevention and control practices and ongoing infection surveillance. This finding was found to be evident in the review of infection prevention and control practices and medication administration. The findings include: Infection surveillance is the systematic collection, analysis and interpretation of data related to infections, primarily in healthcare settings, to identify and address outbreaks, trends and risks. It plays a crucial role in preventing and controlling the spread of infections, including healthcare-associated infections (HAIs). On 04/23/2025 at 09:42 AM the surveyor reviewed the facility's Surveillance for Infections Policy which was from MED-PASS, Inc. dated 2001 and revised September 2017. The policy revealed that the facility was to have reports available for gathering surveillance data, data collection and recording, calculating infection rates, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0921 — failed to keep a safe, functional, sanitary building — isolated
    Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observation, and interview, it was determined that the facility failed to keep a sanitary environment. This was evident in the Kitchen during the facility's annual recertification survey. The findings include: On 4/22/25 at 7:07AM during a tour of the Kitchen, the surveyor observed the floor on both sides of the dishwasher and the floor under the sink located next to the dishwasher were covered with mineral deposit/build up. The surveyor notified the Food Services Director (FSD) who walked over to the area and confirmed the findings. I will get it cleaned. On 04/25/25 at 3:15 PM the surveyor informed the Administrator of the findings.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2025-04-25 · tag F0947 — failed to train nurse aides adequately — isolated
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility staff interviews and employee record reviews, it was determined that the facility failed to ensure that the required in-service training for nurse aides was completed. This finding was found to be evident in 3 out of 3 employee personnel files (#10, #11 and #14) reviewed for the annual required in-service training for nurse aides. The findings include: On 04/24/2025 at 07:15 AM the surveyor reviewed 3 nurse aide employee personnel files #10, #11 and #14. During the record review of the 3 nurse aide personnel files it was revealed that the facility had incomplete documentation on the annual required in-service training for the 3 nurse aides #10, #11 and #14. Further review of the nurse aide personnel files revealed that nurse aides #11 and #14 had Dementia Training certificates (6 hour Cognitive training course) dated 3/19/2018 and 10/10/2022 respectively. At 07:45 AM on 04/24/2025 the surveyor interviewed the Director of Nursing (DON). During this interview the surveyor conveyed to the DON that the 3 nurse aide personnel files #10, #11 and #14 had incomplete…

    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 · D2024-08-02 · tag F0625 — isolated
    Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, the facility failed to provide written notice to the resident or resident representative of the facility's bed hold policy. (Resident # 2). This was evident in 1 of 5 residents reviewed during a complaint survey. Findings includes: Review of resident #2's medical records on 7/30/24 at 11:12am revealed the resident was transferred from the facility after exhibiting behavioral issues that put the resident and other residents at risk. The resident was transferred to a local hospital for emergency psychiatric evaluation on 8/28/21 and did not return to the facility. Continued review of resident #2's medical records revealed no evidence that the facility provided the resident or his/her representative with a bed hold policy. Also, there was no evidence of a provider discharge summary on the resident's medical record 30 days after the resident transferred to the local hospital. Interview with the Social Worker Director #3 on 7/31/24 at 12:00pm revealed the facility failed provide a bed hold policy to the resident or the resident representative…

    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 · D2024-08-02 · tag F0626 — isolated
    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review and interview, the facility failed to allow a resident (resident #2) to return to the facility after transfer for emergency treatment. This was evident for 1 of 5 residents reviewed during a complaint survey. Findings include: Review of resident #2's medical records on 7/30/24 at 11:12am revealed the resident was transferred from the facility after exhibiting behavioral issues that put the resident and other residents at risk. The resident was transferred to a local hospital for emergency psychiatric evaluation on 8/28/21 and did not return to the facility. Continued review of resident #2's medical records revealed no evidence that the facility provided the resident or his/her representative with a bed hold policy. Also, there was no evidence of a provider discharge summary on the resident's medical record 30 days after the resident transferred to the local hospital. Interview with the complainant on 7/31/24 at 12:24pm. The complainant revealed that he/she was the Director of Behavioral Health for the local hospital to which resident #2 was sent for…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-02 · tag F0661 — isolated
    Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on record review and interview, it was determined that the facility failed to place a discharge summary on a resident's (resident #2) medical record after discharge. This was evident for 1 of 5 residents reviewed in a complaint survey. Findings includes: Review of resident #2's medical records on 7/30/24 at 11:12am revealed the resident was transferred from the facility after exhibiting behavioral issues that put the resident and other residents at risk. The resident was transferred to a local hospital for emergency psychiatric evaluation on 8/28/21 and did not return to the facility. Continued review of resident #2's medical records revealed no evidence that the facility provided the resident or his/her representative with a bed hold policy. Also, there was no evidence of a provider discharge summary on the resident's medical record 30 days after the resident transferred to the local hospital. Interview with the Administrator on 7/31/24 at 1:29pm confirmed that the facility failed to place a provider discharge summary on resident #2's medical record after discharge.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2021-04-09 · 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

    Based on surveyor review of the clinical records and staff interviews, it was determined that facility staff failed to provide evidence that a baseline care plan was done and provided to the resident/representative. This finding was evident for 3 out of 19 residents reviewed during the annual survey (Residents #6, #11, and #193). The finding includes: 1. On 04-07-2021, a review of Resident #6's clinical record revealed a physician order dated 01-08-2021 for the placement and monitoring of a wander guard bracelet (a sensor on a band used as an elopement prevention device). However, further review of the resident's clinical record revealed no documented evidence of a base line care plan for elopement and the use of a wander guard bracelet. On 04-08-2021 at 3:00 PM, interview with the Director of Nursing revealed no additional information. 2. On 04-07-2021, a review of Resident #11's clinical record revealed a physician order dated 01-11-2021 for the placement and monitoring of a wander guard bracelet (a sensor on a band used as an elopement prevention device). However, further review…

    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 · D2021-04-09 · 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 clinical record reviews and interviews with the facility staff, it was determined that the facility staff failed to follow a physician's order and failed to provide care in accordance with professional standards of practice. This was evident for 2 out of 19 residents selected for review during the survey (Resident #7 and #11). The finding includes: 1. On 04-07-2021 a review of Resident #7's clinical record revealed on 03-03-2021 a physician tube feeding order for a 200 ml water flush to be given at 12:00 AM and 5:00 AM for hydration. Further review revealed Resident #7's was admitted to the facility with a percutaneous endoscopic gastrostomy tube (PEG) to receive artificial nutrition. A PEG tube is used to provide a route for artificial nutrition, hydration, and medication administration in residents who are likely to have prolonged inadequate or absent oral intake. However, a review of the enteral feeding record for March and April 2021 revealed there was no documented evidence that the 12:00 AM flush was given from 03-03-2021 through 04-07-2021. On 04-08-2021 at 3:00 PM,…

    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 before2021-04-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on surveyor review of the clinical record, it was determined that the facility staff failed to ensure that a resident receiving psychotropic medication had an appropriate clinical indication for the use of the psychotropic medication and failed to provide behavior monitoring for the use of the medication. This finding was evident for 1 of 5 residents selected for unneccessary medication review during the survey (#32). The findings include: A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. On 04-08-21, review of the clinical record for resident #32 revealed a physician's order written on the day of admission [DATE]) for the antipsychotic medication Seroquel, 25mg at bedtime. Further review of the clinical record revealed no diagnosis of psychosis. However, there is a care plan for psychotropic medications related to psychosis for behavior management. In addition, a physician's history and physical note written on 02-22-21 lists dementia, on Seroquel…

    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 · E2019-07-11 · tag F0925 — failed to control pests — pattern
    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor tour of the facility's kitchen and nursing units, it was determined that the facility staff failed to ensure that the facility was free of pests. This was evident in the kitchen and the first- floor unit. The findings include: On 07-08-19 at 09:15 AM, surveyor tour of the facility kitchen revealed multiple fruit flies around the dish washer drain. Further observation revealed more fruit flies flying over food serving area and the dirty dish sink area. On 07-09-19 at 10:15 AM, more fruit flies were observed around the nursing station on the first- floor unit and in the dinning room area. Additional observation revealed resident #22, swatting at a fruit fly which was attempting to land on his/her coffee cup. Surveyor interview with resident #22 revealed that he/she was bothered by the presence of the little flies. On 07-09-19 at 11:10 AM, surveyor review of the facility's pest control log revealed multiple visits, with the last visit on 07-01-19. Further review revealed that the general target for the treatments were mice and rats. There was no evidence that fruit…

    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.

    Environmental Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-11 · 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 — the official record, unedited, may be distressing

    Based on surveyor observation and review of the clinical record, it was determined that facility staff failed to develop a plan of care to address a resident's restorative care program. This finding was evident in 1 of 16 residents reviewed during the survey. (#25) The findings include: On 07-09-19 at approximately 10:41 AM, during the initial screening of resident #25, surveyor observed resident to have limited range of motion to both lower extremities. Review of the clinical record revealed a Minimum Data Set which also documented decreased range of motion in both lower extremities. On 03-03-19, a restorative care program was developed by the rehab department however there was no evidence in the clinical record that the recommended restorative program had been incorporated into the resident's plan of care. On 07-09-19 at 1:20 PM, interview with the upper level's unit manager revealed no additional information.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-11 · tag F0657 — failed to keep the care plan current — isolated
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor observation, review of the clinical record and resident interview, it was determined that the facility staff failed to demonstrate the residents active participation in care planning, failure to adhere to the interventions documented in the care plan, and failure to revise the care plan to reflect the resident's current physical and psychosocial needs. This finding was evident in 1 of 3 residents selected for the care plan review. (#32) The findings include: On 07-08-19 at 2:51 PM, resident #32 was observed lying supine in the bed with contracted bilateral lower extremities. Review of the clinical record also revealed a recommendation for a restorative care program for resident #32, secondary to the diagnosis of paraplegia of the bilateral lower extremities, dated 05-15-19. On 05-15-19, there was a rehab addendum note which stated resident refused to continue participation in the restorative program. At the time of survey, the care plan had not been revised to reflect the recommendation for a restorative program for resident #32, nor did it reflect refusal for…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0688 — failed to keep residents mobile / prevent decline — isolated
    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor observation, review of the clinical record, and staff interview, it was determined that the facility staff failed to ensure that a recommended restorative care program was implemented. This finding was evident in 1 of 3 residents selected for review of the limited range of motion care area.(#25) The findings include: On 07-09-19 at 10:40 AM, observation of resident #25 revealed the resident had contractures (shortening and/or hardening of muscles tendons or other tissue) of the bilateral lower extremities. Review of the clinical record revealed a restorative care program, written by the rehab department and dated 03-04-19, that recommended that resident #25 receive passive range of motion (PROM) to the bilateral lower extremities, hip, knee and ankle five times per week for 90 days. Passive range of motion moves the joint with no effort from the patient (someone else independently moves the joint). Further review of the clinical record revealed that the resident received the recommended restorative care during the month of March and was transferred out to the…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0756 — failed to review each resident's drug regimen — isolated
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on surveyor review of resident #42's clinical record and interview of the facility staff, it was determined that the consultant pharmacist failed to identify an irregularity during the monthly drug regimen reviews. This finding was evident for 1 of 6 residents selected for the unnecessary medication review. (#42) The findings include: On 07-11-19, review of resident #42's clinical record revealed that, on 03-30-19 the attending physician ordered a psychotropic medication to be administered as needed at bedtime. The physician did not indicate an end-point at 14 days. Furthermore, there was no evidence in the clinical record that the prescribing physician documented the rationale for the extended use beyond the 14 days, as required. Further review of the pharmacist's medication regimen review revealed that the pharmacist reviewed resident #42's medication records in April, May, and June 2019 and documented that there was no identified irregularity. On 07-11-2019, surveyor interview with the Director of Nursing provided no additional information

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-11 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on surveyor review of the clinical record and interviews with facility staff, it was determined that the facility failed to discontinue or re-assess the need for the use of a PRN (as needed) psychotropic medication beyond 14 days. This finding was evident for 1 of 6 residents selected for the Unnecessary Medication Review. (#42) The findings include: A psychotropic drug is any drug that affects the mind, emotions or behavior. On 07-11-2019, surveyor review of resident #42's clinical records revealed an order, dated 03-30-19, for a psychotropic medication as needed at bedtime for agitation/sleep. Further review of the physician's orders for resident #42 revealed that the physician did not indicate an end-point at 14 days. Furthermore, there was no evidence in the clinical record that the prescribing physician documented the rationale for the extended use beyond the 14 days as required. On 07-11-2019, surveyor interview with the Director of Nursing provided no additional information.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-07-11 · tag F0807 — failed to offer suitable drinks — isolated
    Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on surveyor observation, review of clinical records, and staff interview, it was determined that the facility failed to provide liquids thickened to a consistency determined necessary to meet the resident's clinical needs. This finding was evident for 1 (#35) of 2 residents selected for review of the hydration care area. The findings include: On 07-08-19 at 9:21 AM, resident #35 was observed with a breakfast tray in the room. Surveyor also observed a picture on the wall in the resident's room which indicated that the resident was to be on honey thickened liquids. Surveyor also observed a carton of regular milk and a carton of orange juice on the breakfast tray, both were regular consistency. On 07-09-19 at 8:36 AM the breakfast tray was served to resident #35 with a carton of regular milk and a carton of orange juice. Both the milk and orange juice were regular, non-thickened consistency. On 07-09-19 at 8:40 AM, staff nurse #4 witnessed the tray served with the wrong consistency of liquids. Staff nurse #4 acknowledged resident #35 was to have all liquids thickened to a honey…

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

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-07-11 · 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 surveyor review of facility antibiotic stewardship program and policies and infection control policies, it was determined that the facility staff failed to review and revise infection control policies and practices annually. In addition, facility staff failed to utilize the appropriate product to disinfect a glucometer. This finding was evident on 1 of 2 nursing units. The findings include: 1. On 07-12-19 at 3:30 PM, surveyor review of facility infection control program and policies with the Director of Nursing (who serves as the infection control nurse) revealed that the infection control team meets monthly and discusses ongoing infection related issues. However, review of facility policies and procedure revealed that the policy hhad not been revised since 2014. Additionally, there was no evidence that the antibiotic stewardship program had been reviewed since 2016. On 07-12-19 at 4:10 PM, surveyor interview with the director of nursing revealed no new information.2. On 07-12-19 at 2:00 PM, during inspection of the medication cart on the upper level nursing unit, revealed…

    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
  • No harm found · Ccited before2019-07-11 · tag F0730 — widespread
    Observe each nurse aide's job performance and give regular training.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on surveyor review of employee files and facility staff interview, it was determined that the facility staff failed to complete a performance review for nurses aides at least once every 12 months. This was evident in 3 of 3 employee records reviewed during the survey. The findings include: On 07-11-19 at 3:22 PM, surveyor review of employee files for Geriatric Nursing Assistants (GNA) #1,#2 and #3 revealed that their last performance reviews were on 07-19-17. There was no evidence that the facility staff completed annual performance reviews for GNA #1 #2 and #3 in 2018 as required. On 07-11-19 at 4:10 PM, surveyor interview with Director of Nursing (DON) revealed no new information.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • No harm found · Bcited before2019-07-11 · tag F0842 — failed to keep accurate, complete medical records — pattern
    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 surveyor review of the clinical record and interview of the facility staff, it was determined that the resident's attending physician failed to accurately document on a resident's Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form. Maryland MOLST is a portable and enduring form for orders about cardiopulmonary resuscitation (CPR) and other life-sustaining treatments including artificial ventilation, blood transfusion, hospital transfer, medical work up, antibiotics, artificially administered fluids and nutrition and dialysis. This finding was evident for 1 of 1 residents selected for the advance directive review (#6). The findings include: On 07-10-19 at 10:15 AM, surveyor review of resident #6's MOLST, signed on 10-23-17, revealed that the primary physician documented that resident #6's MOLST was completed based on the wishes of the resident's health care agent, as named in the resident's advance directive. However, there was no evidence of advance directive in resident #6's clinical record. On 07-10-19 at 11:10 AM, surveyor interview with the social worker…

    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

“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

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
MEYER, TONIIndividual5% OR GREATER DIRECT OWNERSHIP INTEREST50%since 05/01/2010
MEYER, PHILIPIndividualDIRECT OWNERSHIP INTEREST; 5% OR GREATER MORTGAGE INTEREST; MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/01/2010

CMS files one row per role, so the 8 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted.

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.

$6.3M
Net patient revenuemost recent cost report
+10.3%
Operating marginrevenue minus expenses
$600K
Related-party expense11% of expenses
Who pays — share of resident-days
Medicaid 49%Medicare 10%Other / private 41%

This home reported $600K paid to related parties — landlords or management companies under common ownership — equal to about 11% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$335per resident / day
operating cost
$10,195per month
≈ monthly operating cost
$374per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in MD

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215228. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-04-25, 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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