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Bedford Court Healthcare Cent.

3701 International Drive, Silver Spring, MD 20906 · For profit - Limited Liability company · 60 certified beds · (301) 598-2900 Medicare & Medicaid certified

Call the home — (301) 598-2900 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
No harm-level citations or fines — but 28 lower-level deficiencies on record (see below)
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
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • a high number of inspection citations overall (28) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags

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

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

5/5
CMS overall
5 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 5 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3801 International Drive (Lesurie Plaza) Suite 210 · (301) 562-7200 · Call to confirm hours
Pharmacy
3860 International Dr · (301) 598-3208 · Call to confirm hours
Grocery
3860 International Dr · (301) 598-4666 · Call to confirm hours
Park
16601 Georgia Ave · (301) 774-6255 · Typically dawn to dusk
Place of worship
3680 S Leisure World Blvd · (301) 598-5312

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 5 of 5
Long-stay residentspeople who live here 4 of 5
Short-stay residentsrehab / post-hospital 5 of 5

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 5 stars. From monthly CMS archive snapshots.

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

Overall rating5★
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 increased10.0%20.4%15.4%better
Long-stay residents who lose too much weight7.1%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 infection1.0%1.5%2.0%better
Long-stay residents with depressive symptoms0.0%22.8%6.5%check this — see note marked star 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 injury2.9%2.4%3.3%better
Long-stay residents on antianxiety or hypnotic medication25.7%16.7%18.9%worse
Long-stay residents given the seasonal flu vaccine89.7%96.6%95.3%typical
Long-stay residents with pressure ulcers8.7%5.9%4.7%worse
Long-stay residents with worsening bladder/bowel control31.4%25.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table17.6%13.8%17.1%typical
Short-stay residents who newly got an antipsychotic medication1.2%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine84.3%80.6%79.4%typical
Short-stay residents rehospitalized after admission21.1%21.0%22.6%typical
Short-stay residents with an outpatient ER visit7.4%9.8%12.0%better
Long-stay hospitalizations per 1,000 resident days0.831.331.67better
Long-stay outpatient ER visits per 1,000 resident days0.191.201.80better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

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

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

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

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

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

73.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 336 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

73.0%U.S. median 51.5%
Got home and stayed home
12.5%U.S. median 10.7%
Went back to hospital
62.5%U.S. median 56.6%
Met the expected recovery
0.58U.S. median 0.31
Therapy hours / resident / day
0.32hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.04hours / resident / day
Speech therapy

Met the expected recovery: 62.5% 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 160 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 0.58 therapist hours per resident per day in 2026Q1 — more than 87% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 17% 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 SNF73.0%CMS range 68.3–77.451.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF12.5%CMS range 9.6–15.510.7%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 discharge62.5%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 discharge71.2%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 discharge48.1%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified100.0%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting100.0%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge99.3%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 worsened1.6%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 hospitalization6.4%CMS range 4.0–10.57.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 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

0.62
RN hours/ resident / day
1.46
LPN hours/ resident / day
2.98
Aide hours/ resident / day
5.06
Total nurse hours/ resident / day
0.39
RN hoursweekends
19.1%
Total nursing turnover
50.0%
RN turnover

How full it usually is: this home is certified for 60 beds and averages 42.6 residents a day — about 71% occupied, or roughly 17 beds typically open. It usually has some room. 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 5.06 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.62 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.98 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.58 hrs/resident/day on weekends vs 5.25 on weekdays — 13% thinner on weekends. RN hours go from 0.71 to 0.39 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%. 4 administrators have left in the past year — frequent leadership churn is a warning sign families often miss.

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

10
deficiencies at the latest standard inspection (2026-03-20)
13
at the previous standard inspection (2024-12-12)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

28 citations, most serious first. The 10 most serious are shown; the remaining 18 are one tap away and print in full.

  • Potential for harm · F2026-03-20 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interviews, it was determined that the facility failed to store and process linens to prevent the spread of infection. This was evident for 1 out of 1 observation made in the facility's laundry room. The findings include: On 03/19/2026 at 8:47 AM, an observation of the laundry room revealed that clean laundry was stored uncovered. This included towels, placed on a rectangular table, clean tablecloths on a metal rack, an additional metal rack containing tablecloths, bed sheets, towels, and clothing, and clean linens in a basket all of which were uncovered. On 03/19/2026 at 8:47 AM, an interview with the Housekeeping Director (Staff #12) revealed that the laundry room typically had uncovered linen. On 03/19/2026 at 9:28 AM, an interview with the Director of Nursing revealed that the expectation was for linen to be covered.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-20 · tag F0761 — failed to label and store drugs safely — pattern
    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 observation, record review, and staff interview, it was determined that the facility failed to ensure that controlled substances were consistently accounted for and documented through the required dual nurse signatures during shift-to-shift narcotic counts. This was evident for 2 (Choice and Independent) out of 3 units during the facility's recertification survey.The findings include:On 03/17/2026 at 9:18 AM, following an observation of a medication pass conducted by the surveyor on the choice unit with Licensed Practical Nurse (LPN) #7, the surveyor reviewed the narcotic control book and identified a missing signature for the incoming nurse on 03/13/2026 for the 3:00 PM to 11:00 PM shift, as well as a missing signature for the outgoing nurse for the 11:00 PM to 7:00 AM shift. LPN #17 was requested to participate in a concurrent review of the narcotic book and she confirmed the date and the absence of the required signatures. On 03/17/2026 at 9:20 AM, during an interview with LPN #7, when asked for the expectation regarding signing in the narcotic book, she stated that at…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-20 · 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 — the official record, unedited, may be distressing

    Based on observations and interviews, it was determined that the facility failed to ensure that food items were stored in a manner that maintained the integrity of the specific items. This was evident for 1 (initial observation) of 2 of the kitchen areas upon facility entry. The findings include: On 03/16/2026 at 8:05 AM, an observation of the kitchen revealed a tray of freshly cooked chicken in the refrigerator that was uncovered. On 03/16/2026 at 8:07 AM, an observation of the kitchen's dry storage revealed a packet of crackers that was unlabeled. On 03/16/2026 at 8:10 AM, an observation of the kitchen's freezer revealed unlabeled shrimp, cinnamon sticks, and chicken. On 03/17/2026 at 12:24 PM, an interview with the Dining Services Director (Staff #3) revealed that the expectation was that the food items should have been labeled and not left uncovered. On 03/18/2026 at 9:05 AM, the concerns were addressed with the Director of Nursing and she indicated that she understood.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-03-20 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of facility documents and interviews, it was determined that the facility failed to: 1) conduct quality assurance meetings on a quarterly basis, and 2) ensure the presence of required quality assurance committee members in meetings. This was evident during the quality assurance and performance improvement task conducted as part of the recertification survey process. The findings include:QAPI (Quality Assurance and Performance Improvement) is a data-driven, proactive approach to healthcare management, mandated by CMS for nursing homes and home health agencies, merging Quality Assurance (QA) with Performance Improvement (PI) to improve patient care, safety, and quality of life.On 03/19/2026 at 10:04 AM, the surveyor requested QAPI attendance sheets for the past 12 months.On 03/19/2026 at 12:00 PM, an interview with the Facility's QAPI coordinator, Staff #1, was conducted. She reported that the facility's QAPI binder was missing and that she could not find attendance sheets for April 2025, May 2025 and October 2025. When asked when quarterly QAPI meetings were held, she…

    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 · E2026-03-20 · tag F0944 — pattern
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    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 staff received ongoing Quality Assurance and Performance Improvement (QAPI) training. This deficient practice was identified in 5 of 5 employee files reviewed during the facility's recertification survey.The findings include:On 03/19/2026 at 7:44 AM, a review of employee records for Registered Nurse (RN) #16, Licensed Practical Nurse (LPN) #17, and Geriatric Nursing Assistants (GNAs) #18, #19, and #20 revealed no evidence of ongoing QAPI training following initial hire. Hire dates for the GNAs ranged from 2003 through 2025, indicating employment without documented continuation of QAPI education.On 03/19/2026 at 11:17 AM, during an interview, the Human Resources (HR) Director, when asked who was responsible for ensuring staff members maintained required training, she stated that she was responsible. When asked to provide documentation of QAPI training for the identified employees, she stated she would locate and provide the records.On 03/19/2026 at 12:49 PM, the HR Director reported that…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-20 · tag F0644 — isolated
    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that that the facility failed to refer a resident for a PASARR evaluation review after a new mental health diagnosis.This was evident for one (Resident # 4) out of five residents reviewed for unnecessary medications.The findings include:A review of Resident # 4's medical record on 3/17/26 revealed Resident # 4 was admitted to the facility on [DATE] with diagnoses that include: dementia, generalized anxiety disorder and major depressive disorder. An admission PASARR (preadmission screening and resident review) level I screen dated 7/14/21documented Resident # 4 as not having any mental health or intellectual disability or related conditions.Further review of Resident # 4's medical record revealed that Resident # 4was diagnosed with bipolar disorder on 1/9/26. There was no evidence in Resident # 4's medical record that a new PASARR screening was completed after the addition of this mental health diagnosis.In an interview with Staff # 2 (social service…

    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 before2026-03-20 · 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 observations, record reviews, and interviews it was determined that the facility failed to develop and/or update residents care plan. This was for 2 (Resident #1 and #49) out of 3 residents reviewed for care plan during the recertification survey. The findings include: A care plan is a simple written plan that explains how to take care of a resident's health and daily needs. It lists what the resident needs help with, what their goals are, and what caregivers should do to help them. It makes sure everyone helping the resident knows the same plan so the care stays organized and consistent. 1). On 03/16/2026 at 8:57 AM, an observation of Resident #1 revealed that the resident was receiving oxygen therapy. On 03/17/2026 at 8:55 AM, record review revealed that Resident #1's MDS (Minimum Data Set) the resident was on oxygen therapy. At the same time, further review of the comprehensive care plan revealed no goals, or interventions addressing oxygen therapy, including administrations, monitoring or safety precautions. On 03/18/2026 at 8:57 AM, an interview with the 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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-20 · tag F0658 — failed to meet professional standards of care — isolated
    Ensure services provided by the nursing facility meet professional standards of quality.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and interviews it was determined that the facility failed to maintain professional standards of practice related to: 1) oxygen orders and 2) providing sufficient documentation to support a new mental health diagnosis. This was evident for 2 (Resident #1 and #4) out of 6 residents reviewed for respiratory orders and unnecessary medications during the recertification survey. The findings include: 1). On 03/16/2026 at 8:57 AM, an observation of Resident #1 revealed that the resident was receiving oxygen therapy. On 03/16/2026 at 9:55 AM, record review failed to reveal an active order for oxygen. On 03/18/2026 at 8:57 AM, an interview with the Director of Nursing revealed that the expectation was that if a resident was on oxygen, there should be an order to reflect it. 2) The DSM-5 (Diagnostic and Statistical [NAME] of Mental Disorders, Fifth Edition) is the standard of care for diagnosing and treating patients with mental health conditions. The DSM- 5 Bipolar Disorder Adult…

    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 before2026-03-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interview, it was determined that the facility failed to maintain good grooming and personal care services for Resident # 6. This was evident for one (Resident # 6) out of one resident reviewed for Activities of Daily Living (ADLs).The findings include: During screening on 3/16/26 (Monday) at 9:08 AM, Resident # 6 was observed to have greasy hair. When interviewed about ADLs, Resident # 6 stated, .I only remember getting showered one time when I got my hair washed.During an observation on 3/19/26 at 9:13 AM, Resident #6 was in bed in a hospital gown and his/her hair appeared greasy. Resident #6 stated, I think I had a bath yesterday . I am not sure when my hair was washed last. During an interview on 3/19/26 at 9:49 AM, Staff # 11 (LPN) stated, We [staff] document showers/baths in the Task Tab in the [medical record system]. We don't use a shower book in this facility.A review of Resident # 6's medical record on 3/19/26 (Thursday) at 11:14 AM revealed Resident # 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-03-20 · 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 interviews, observations and record reviews, it was determined that the facility failed to: 1) provide appropriate treatment to maintain an individual's limited range of motion, and 2) evaluate a resident for therapy services to prevent further decline in the range of motion. This was evident for 1 (Resident #19) out of 6 residents reviewed for position and mobility during the recertification survey. The findings include:On 03/16/2026 at 8:40 AM, an interview with Resident #19 was conducted. The resident reported that they had a stroke during their stay at the facility and that they wore a splint on their right hand, but the therapy services took it away.During the interview, the surveyor observed that Resident #19 had a contracture on the right hand. When asked if they were receiving any therapy services, the resident stated that they had not had therapy services for a long time. On 03/17/2026 at 9:04 AM, a review of Resident #19's medical records was conducted. The care plan indicated that the resident had musculoskeletal condition, hemiparesis and contracture on 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
Show the remaining 18 citations
  • Potential for harm · D2026-03-20 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, it was determined that the facility failed to verify the accuracy of hospital discharge paperwork prior to placing admission medication orders for newly admitted residents. This was evident for 1 (Resident #40) out of 20 residents reviewed during the survey.The findings include: On 03/18/2026 at 11:44 AM, the surveyor began reviewing a complaint that stated Resident #40 received incorrect medication on the first 4 days of their stay.On 03/18/2026 at 12:02 PM, record review revealed that Resident #40 was admitted to the facility from the hospital on [DATE]. Discharge paperwork from the hospital dated 02/20/2026 reflected that the resident was prescribed the following medication at the hospital: Eliquis (blood thinner) 5 mg by mouth twice daily, amiodarone (blood pressure medication) 200 mg 1 tablet by mouth once daily, and Buspirone (anxiety medication) 5 mg take 1 tablet by mouth twice daily.Facility records indicated that orders were entered for Eliquis (blood thinner) 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-12 · tag F0684 — failed to provide proper treatment and quality of care — pattern
    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 observation, record review and interview, it was determined the facility failed to 1) obtain physician orders for residents to receive Continuous Positive Airway Pressure (CPAP) treatment and 2) maintain Quality of Care. This was evident for 3 (Resident #17, #8 and #292) of 24 residents reviewed during the annual survey The findings include: 1) CPAP treatment, which stands for Continuous Positive Airway Pressure, is a therapy that uses a machine to deliver pressurized air through a mask worn while sleeping, keeping the airway open and preventing breathing interruptions caused by sleep apnea. On 12/04/24 at 09:30AM during rounds the surveyor observed a CPAP machine sitting on Resident #17's bedside table. The resident stated he/she had problems sleeping so the machine was used at night. They put it on every night so I could sleep On 12/05/24 at 07:37 AM a review of Resident #17 clinical record confirmed that the resident had been receiving CPAP treatment at night. This was evident in a progress note dated 11/10/24 by Staff #17. Further review of the clinical record 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-12 · tag F0761 — failed to label and store drugs safely — pattern
    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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews it was determined that the facility failed to maintain a safe and effective system for securing medication. This was found to be evident for 3 out of 3 medication carts observed during the re-certification survey. The findings include: During a random tour of the nursing unit conducted on 12/06/24 at 6:12 AM, the surveyors observed an unattended medication cart unlocked. The surveyors were able to open each drawer that contained prescribed and over the counter medications. In addition, the laptop was open to resident names. The medications were labeled with resident names and room numbers. During the continued observation the Surveyors observed RN #3 exit resident room [ROOM NUMBER]. During an interview conducted on 12/06/24 at 6:16 AM, RN #3 apologized for leaving his medication cart unattended and unlocked as well as the laptop open to resident names. The RN stated that he had a rough night but that the facility's policy was to always lock your medication cart when…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2024-12-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with facility staff, it was determined that the facility failed to store and prepare food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility kitchens. The findings include: During observations in the Dining Room Kitchen on 12/04/24 at 08:15 AM, the following items were found: 1 metal container with a lid containing cooked ham labeled with a prepared date of 11/26/24 and a use by date of 11/30/24, 1 unlabeled and undated pack of cheese in clear plastic wrap, 1 undated plastic container labeled [NAME] Krispies, 1 5-pound plastic container of Creamy Peanut Butter that had an open date of 10/02 with no year written on the lid but had no expiration date identified. There was also 1 container of Old Bay seasoning that was labeled with an open date of 09/01/23 and a use-by date of 10/01/23. During an interview with the Lead Dietary Aide #2 On 12/04/24 at 08:15 AM, 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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-12-12 · tag F0814 — failed to dispose of garbage properly — pattern
    Dispose of garbage and refuse properly.
    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 properly dispose of waste in the kitchen area in a manner to prevent contamination and the attraction of pests. This was evident for 1 out of 2 kitchen areas in the facility. The findings include: During the initial tour of the main kitchen on 12/04/24 at 8:36 AM, the Surveyors observed a pile of 14 empty boxes that lay on the floor beside the doorway. The pile of boxes blocked the doors of the free-standing refrigerator, freezer, and holding warmer. An observation of the trash can beside the door was overfull and would not allow the lid to completely close. Several Sysco Classic Sliced [NAME] Potatoes cans were visible on top of the trash holding the lid open. During an interview on 12/04/24 at 08:40 AM, Lead [NAME] #1 said the trash should not be there and needs to be cleaned up. During an interview conducted on 12/04/24 at 9:46 AM, the Dining Service Director stated that the boxes should not have been piled on the floor and the trash overfilled and stated there was no excuse. During an observation…

    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 before2024-12-12 · tag F0868 — pattern
    Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
    What the surveyor found here — the official record, unedited, may be distressing

    Based on interview and record review, it was determined the facility failed to ensure the required staff members were present for each of the monthly Quality Assurance (QA) Committee meetings. This was evident during a review of the Quality Assurance and Performance Improvement (QAPI) program during the recertification survey. The findings include: On 12/11/24 at 9:59 AM, an interview with the Nursing Home Administrator (NHA) was conducted to review the facility's quality assurance activities. Copies of the attendance sheets for the past 6 months' QA meetings were requested. On 12/11/24 at 3:31 PM, a review attendance sheets for the following months revealed: - May: no Director of Nursing (DON), Infection Preventionist (IP), Medical Director (MD) - June: no DON and IP - July: no DON, IP and MD On 12/12/24 at 7:44 AM, the NHA and the General Manager (GM) were notified of the concern related to the required members of the QA committee attending the meeting.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · 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 observation and interviews with residents and staff, it was determined that the facility failed to respect a resident's dignity. This was evident in 1 (Resident #8) out of 6 residents observed for dignity. The findings include: During an observation on 12/04/24 at 12:41 PM Resident #8 was observed sitting in a wheelchair with another resident at the dining room table. Resident #8 was slumped forward asleep with a stream of drool draining from the resident's mouth onto the resident's lap. A plate of food was sitting in front of the resident on the dining room table and no food had been eaten. During continued observation on 12/04/24 at 12:52 PM Resident #8 was observed sitting in a wheelchair asleep. No assistance was being provided by the staff. The surveyor attempted to awaken the resident by saying the resident's name but received no response. A Geriatric Nursing Assistant (GNA) #9 came over to assist. The GNA had to say the resident's name loudly and shake the resident's shoulders to awaken. The resident appeared groggy and would not hold his/her head up. The GNA stated…

    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 · D2024-12-12 · tag F0577 — isolated
    Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
    What the surveyor found here — the official record, unedited, may be distressing

    Based on observations and interview, it was determined the facility failed to ensure that the location of the most recent state survey results and plan of correction were posted in a place readily accessible to residents, family members and visitors. This was evident during the facility's recertification survey. The findings include: The surveyor's observations of the facility on 12/05/24 at 8:00AM and 12/6/24 at 7:30AM did not reveal any posted notification indicating where the recent state survey results and plan of correction were located. On 12/09/24 at 07:56 AM in an interview, the Nursing Home Administrator confirmed that the facility failed to post a sign indicating where the most recent survey inspection was located. The Administrator stated I will take care of that right now After the surveyor's intervention, on 12/09/24 at 09:54 AM the surveyor observed a sign which revealed the location of the recent state survey inspection results, posted in a place easily accessible to any person, on a table in front of the nurse's station.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · 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 interview, it was determined that the facility failed to provide evidence that an advance directive was offered to the residents. This was evident for 2 (Resident #22 and #37) of 4 residents reviewed for advance directives during the recertification survey. The findings include: 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. A Medical Orders for Life-Sustaining Treatment (MOLST) is a medical order form that documents a patient's wishes for end-of-life care. A Brief Interview for Mental Status (BIMS) is a brief cognitive screening measure that focuses on orientation and short-term word recall. On 12/5/24 at 7:45 AM, a review of Resident #22 and Resident #37's paper charts revealed capacity…

    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 · D2024-12-12 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the facility policy and interviews it was determined that the facility failed to ensure that grievance forms were accessible. This was found to be evident for 1 (Resident #244) out of 1 Resident reviewed for the grievance policy. The findings include: A review of a formal complaint MD00203191 filed with the Office of Healthcare Quality was conducted on 12/05/24 at 10:00 AM. The complainant stated that verbal grievances were filed by the Social Service Director on behalf of the complainant and Resident #244. The complainant also reported that a request to receive a copy of the written grievances was denied in accordance with the facility's policy. On 12/05/24 at 10:32 AM review of grievance forms confirmed Resident #244 had 2 investigated grievance forms. During an interview conducted on 12/05/24 at 11:10 AM, the Social Service Director stated that she filed the grievances on behalf of the complainant and Resident #244. The Social Service Director stated that the complainant requested a copy of the grievance forms investigated, however the request was denied…

    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 · D2024-12-12 · 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 develop and implement a comprehensive care plan for the use of a splint. This was evident for 1 (Resident #37) of 32 residents reviewed for care planning 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. On 12/4/24 at 11:32 AM, Resident #37 was observed sitting in the wheelchair and was noted with left arm weakness, his/her arm was supported by a half lap board arm rest attached to the wheelchair, a plastic splint was also noted on the windowsill. On 12/5/24 at 10:02, a review of the physician orders revealed the following: - Start Left upper extremity rigidity splint during day shift. (Can be removed during therapy) every day shift, this order was written on 11/18/2024 - Start Left upper extremity soft brace Elbow QHS (Once a day at bedtime) every evening shift , this order was written on 11/18/2024 On 12/6/24 at 12:30 PM, a 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 · Dcited before2024-12-12 · 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

    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 review and revise the interdisciplinary care plans to reveal accurate interventions to meet the needs of the residents. This was evident for 1 (Residents #17) of 24 residents selected for investigation during the 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 A peripherally inserted central catheter (PICC) line is a thin, flexible tube that is inserted into a vein in the arm or neck and threaded into a large vein in the chest. A PICC line can be used for many types of intravenous treatments. Resident #17 was admitted to the facility on [DATE] with physician orders for intravenous (IV) antibiotic treatment via PICC line for Osteomyelitis. On 12/5/24 at 8:16AM in an interview, Resident #17 informed the surveyor that his/her antibiotic treatment ended about 2 weeks ago 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 · Dcited before2024-12-12 · 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview of staff it was determined that the facility failed to ensure Activities of Daily Living (ADL) was provided. This was found to be evident for 1 (Resident #244) out of 14 Residents reviewed for ADL care. The findings include: A review of a formal complaint MD00203191 filed with the Office of Healthcare Quality was conducted on 12/05/24 at 10:00 AM. The complainant stated that Resident #244 had not received showers as scheduled during his/her stay at the facility. A review of Resident #244's medical records conducted on 12/05/24 at 10:22 AM confirmed the resident shower days were scheduled for Tuesday and Friday evenings. According to the National Institute of Health (NIH) Activities of Daily Living (ADL) are basic self-care tasks which include toileting, dressing, bathing or showering, getting in/out of bed or chairs, and walking. A review of the Resident's medical record revealed Resident #244 was admitted to the facility on [DATE]. A further review of the resident's ADL task…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-12-12 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, clinical record review, and staff interviews it was determined that the facility failed to maintain oxygen therapy equipment according to professional standards of practice. This was found to be evident for 2 (#24 and #11) out of 2 residents reviewed for respiratory care during the annual survey. The findings include: 1) During an observation on 12/04/24 at 11:09 AM, Resident #24's oxygen tubing and the humidification bottle were not labeled. On 12/05/24 at 09:17 AM, review of Resident #11's clinical record revealed the following physician orders: Date 04/26/2024 O2 (oxygen) via NC (nasal cannula) at 3L/min (liters per minute) for chronic obstructive pulmonary disease (COPD) Date 08/16/2022 Change humidifier bottle weekly and PRN (as needed) secondary to pt (patient) on oxygen every night shift every Wednesday and as needed During a second observation on 12/05/24 at 08:30 AM, Resident 24's oxygen tubing and the humidification bottle were not labeled. On 12/06/24 at 11:25 AM, an interview with Licensed Practical Nurse (LPN) #6 revealed that oxygen tubing and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-12-12 · 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 observation, record review and interview, it was determined that the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #3 and #8) of 24 residents reviewed the recertification survey. The findings include: A fever is a body temperature of 100.4°F (38°C) or higher, as measured by a thermometer. On 12/4/24 at 10:49 AM, Resident #3 was observed lying in bed and complained of pain in the left leg with a score of 10/10. The resident was also observed grabbing his/ her left leg and was grimacing. The assigned Licensed Practical Nurse (LPN #8) was made aware and stated that he/she will administer the routine Tylenol order. On 12/9/24 at 8:44 AM, a review of the active pain medication orders and Medication Administration Record (MAR) revealed: 1. Tylenol Extra Strength Oral Tablet 500 MG (Acetaminophen) Give 2 tablet by mouth three times a day for Leg Pain 2. Tylenol Oral Tablet 325 MG (Acetaminophen) Give 1 tablet by mouth every 6 hours as needed for Pain 3. Ibuprofen Oral Tablet…

    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 · D2024-12-12 · 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 — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, and interviews, it was determined that the facility failed to 1) keep a sanitary environment and 2) ensure the facility's equipment was functional. This was evident in the laundry room and for 1 (Resident #8) out of 14 resident rooms observed during the facility's recertification survey. The findings include: 1) On 12/06/24 at 07:50 AM the surveyor did a tour of the laundry room with Staff#15. The surveyor observed the floor tiles in the room with the washing machines were visually dirty with dark colored residue scattered throughout the flooring and an accumulation of dirt between the three washing machines. The wall below the shelf housing the chemicals for the washing machines was peeled and visibly damaged. Also, the wall above the eye wash station had scattered areas of a brown colored substance. Staff #15 acknowledged the surveyor's findings. On 12/06/24 at 8:11AM the surveyor did a walk through with the Housekeeping Supervisor, Staff #16 who confirmed the findings. Staff #16 stated…

    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 before2020-02-27 · 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 surveyor review of the clinical record and interview with facility staff, it was determined that the facility failed to maintain accurately documented electronic records. This finding was evident for 1 of 15 residents selected for review during the survey (Resident #93). The findings include: The Maryland Medical Orders for Life Sustaining Treatment (MOLST) form is a two-page portable and enduring medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a patient's/patient representative's wishes about medical treatments and makes those treatment wishes known to health care professionals. On 02-24-2020, surveyor review of Resident #93's electronic record revealed the resident's code status was listed as do not resuscitate. The code status refers to the level of medical interventions a patient wishes to have if their heart or breathing stops. Surveyor review of the resident's paper copy of the MOLST revealed the attending physician completed the document on 02-14-2020 after a discussion…

    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 · D2020-02-27 · 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 — the official record, unedited, may be distressing

    Based on surveyor review of the clinical record and surveyor interview, it was determined that the facility failed to offer a pneumococcal immunization to 1 of 5 residents selected for immunization review (Resident #2). The findings include: On 02-25-2020 at 8:43 AM, surveyor review of Resident #2' s medical records revealed no documentation that Resident #2 had received the pneumococcal immunization or that their representative had received education about the pneumococcal immunization. Furthermore, there was no documentation that Resident #2' s representative had been given the opportunity to refuse the pneumococcal immunization. On 02-26-2020 at 4:31PM, surveyor interview of the Director of Nursing provided no additional information.

    Infection Control 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.

Part of a chain

This home belongs to SUNRISE SENIOR LIVING — 4 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

RatingThis homeChain avg
Overall 5 of 53.5+1.5 vs chain
Health inspection 4 of 52.8+1.2 vs chain
Staffing 4 of 53.8+0.2 vs chain
Quality measures 5 of 54.8+0.2 vs chain
The other 3 homes this chain runs (chain average 3.5★, per CMS)

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

Owner / managerTypeRoleSince
WELLTOWER OPCO GROUP LLCOrganizationDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2018
WELLTOWER INCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2018
WELLTOWER TRS HOLDCO LLCOrganizationINDIRECT OWNERSHIP INTEREST; ADP OF THE SNFsince 10/01/2018
SUNRISE SENIOR LIVING MANAGEMENT INCOrganizationOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 10/01/2018
BERNSTEIN, CHRISTINAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 11/11/2024
COELHO, ANDREWIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
FALCO, DENISEIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
FRANTZ, EDWARDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
KESSLER, THOMASIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
KIM, CECILIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/07/2022
NASRAWY, CINDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 05/13/2024
O'RIORDAN, DAMIENIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
PAINTER, DAVIDIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
ROYAL, PATRICIAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
SEKEL, WENDYIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
THOMPSON, LISAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 08/23/2022
WELLS, ANJAIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/16/2025
HARRIS, TONYIndividualADP OF THE SNFsince 01/16/2025

CMS files one row per role, so the 35 rows in the source record cover these 18 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.

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

Follow the money — this home’s finances

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

$23.1M
Net patient revenuemost recent cost report
+0.1%
Operating marginrevenue minus expenses
Who pays — share of resident-days
Medicaid 7%Medicare 6%Other / private 87%

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

$234per resident / day
operating cost
$7,103per month
≈ monthly operating cost
$234per 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 215246. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-20, 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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