Willowbrooke Court Skilled Care Center Fairhaven
7200 Third Avenue, Sykesville, MD 21784 · Non profit - Corporation · 79 certified beds · (410) 795-8800 Medicare & Medicaid certified
This home has serious findings on its record. Read them closely before you consider it.
- a middle-of-the-pack inspection score (3/5)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (5/5)
- it has an abuse, neglect, or exploitation citation (F0600), cited Jul 2025
- it has citations for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609, F0610) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (32) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- its payroll-based staffing score sits well above its independent inspection score
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 3 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Worth a closer look. This home's staffing rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the staffing score rests on the facility's own payroll (PBJ) submissions — so a gap this large is worth reading the inspection record for.
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 3 of 5 |
| Long-stay residentspeople who live here | 3 of 5 |
| Short-stay residentsrehab / post-hospital | 3 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating 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.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 18.2% | 20.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 13.4% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 2.9% | 0.5% | 0.9% | worse |
| Long-stay residents with a urinary tract infection | 1.6% | 1.5% | 2.0% | better |
| Long-stay residents with depressive symptoms | 0.0% | 22.8% | 6.5% | check this* — see note marked star below the table |
| Long-stay residents who were physically restrained | 0.0% | 0.0% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 4.6% | 2.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 21.0% | 22.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 17.2% | 16.7% | 18.9% | typical |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 96.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 3.7% | 5.9% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 18.3% | 25.0% | 21.2% | better |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 3.8% | 13.8% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 87.8% | 80.6% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 23.2% | 21.0% | 22.6% | typical |
| Short-stay residents with an outpatient ER visit | 15.5% | 9.8% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 3.10 | 1.33 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.04 | 1.20 | 1.80 | worse |
* 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.
68.3% 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 79 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 44.6% 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 56 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 0.92 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 7% 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
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 68.3%CMS range 57.6–76.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 12.1%CMS range 7.5–18.0 | 10.7% | Oct 2022–Sep 2024 | no 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 discharge | 44.6% | 56.6% | Oct 2024–Sep 2025 | CMS 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 discharge | 55.4% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 33.9% | 50.0% | Oct 2024–Sep 2025 | CMS 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 identified | 94.1% | 98.7% | Oct 2024–Sep 2025 | CMS 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 setting | not 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 discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS 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 stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 1.5% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 5.7%CMS range 2.8–10.1 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.93 | 1.02 | Oct 2022–Sep 2024 | CMS 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
How full it usually is: this home is certified for 79 beds and averages 40.6 residents a day — about 51% occupied, or roughly 38 beds typically open. It often has substantial empty capacity — worth asking why, since low census can reflect either a new or shrinking home or one families are avoiding. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.51 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.37 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.28 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 3.95 hrs/resident/day on weekends vs 4.74 on weekdays — 17% thinner on weekends. RN hours go from 1.52 to 1.01 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 51% is about the same as the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
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.
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.
32 citations, most serious first. The 11 most serious are shown; the remaining 21 are one tap away and print in full.
- Actual harm · G2022-06-02 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolatedEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a facility reported incident, reviews of a medical record, and staff interview, it was determined that the facility staff failed to: 1) follow Resident #15's plan of care and prevent injury to a resident during incontinence care. This resulted in harm to Resident #15; 2) provide adequate supervision of Resident #17 to prevent unsafe wandering/elopement. Although this noncompliance resulted in no actual harm Resident #17, it has a potential for more than minimal harm if the practice is not corrected. This occurred for 2 of 8 residents reviewed during a Long-Term Care Survey Process annual recertification survey. The findings include: A review of facility-reported incident MD00175591 on [DATE] revealed that Resident #15 while being cared for on [DATE] at 1:20 AM, rolled out of bed onto the floor. X-rays were obtained and confirmed a right arm fracture and pelvic fracture. Review of the medical record on [DATE] revealed Resident #15 was admitted to the facility in [DATE] with diagnoses that included a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-07-18 · tag F0804 — failed to serve food at safe, palatable temperature — widespreadEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.
What the surveyor found here — an excerpt from the official record, may be distressing
Number of residents sampled: Number of residents cited: Based on observation and interview, it was determined the facility failed to provide food at an appetizing temperature. This was evident for 1 out of 1 observation of a meal and test tray. The findings include:On 07/17/2025 at 12:02 PM, the surveyor observed the start of the lunch meal on the first floor pine view unit dining area. The plates were prepared in the kitchenette within the dining area, from prepared food that was kept on steam tables.On 07/17/2025 at 12:47 PM, the surveyor observed the dining staff prepare the test tray plate.On 07/17/2025 at 12:49 PM, the test tray left the kitchenette on a cart with other trays, which belonged to residents who were eating lunch in their rooms. On 07/17/2025 at 12:51 PM, the test tray arrived in the prospective hallway. The staff began to deliver the trays which belonged to residents, which were on the same cart as the test tray.On 07/17/2025 at 12:52 PM, the last resident tray had been delivered. The surveyor requested Medical Dietary Aide (Staff #8), who was present at the time,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-07-18 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Number of residents sampled: Number of residents cited: Based on observations and staff interviews, it was determined that the kitchen failed to ensure food items were stored to maintain the integrity of the specific items. This was evident for the initial observation of the kitchen upon facility entry. This failure has the potential to affect all residents.The findings include:On 07/15/2025 at 7:41 AM, an observation of the kitchen revealed the first of three walk-in refrigerators, which had opened and unlabeled bologna and opened and unlabeled salami.On 07/15/2025 at 7:43 AM, an observation of the second of three walk-in refrigerators revealed opened and unlabeled feta cheese, opened and unlabeled parmesan cheese, and opened and unlabeled yellow american cheese.On 07/15/2025 7:48 AM, an observation of the dry storage room revealed opened and unlabeled linguine pasta, opened and unlabeled graham cracker crumbs, an opened container of brown rice labeled use by 9/17/24, an opened container of panko bread crumbs labeled use by 2/1/25, and an opened bag of pecans dated 7/8/25.On…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-07-18 · tag F0657 — failed to keep the care plan current — patternDevelop 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 resident and representative interviews, record reviews, and staff interview, it was determined the facility failed 1. to include the resident or their representative in the care planning process, 2. update and revise the care plan to accurately reflect the resident's current interventions and treatments. This was evident in 4 (Resident #3, #31 #35, and #44) out of 12 residents reviewed for care planning. The findings Include: 1a. On 7/15/2025 at 8:56 AM, An interview was conducted with Resident #35. The resident stated that they cannot remember if they have been to a care plan meeting. On 7/15/2025 at 10:24 AM, Record review of Resident #35's electronic health record was conducted. No documentation found regarding care plan meetings in the year of 2025. Latest care plan meeting signature sheet found in the resident's record was from October 2024. On 7/16/2025 at 11:18 AM, An interview was conducted with the Assistant Director of Nursing (ADON). When asked when the facility conducts care plan meetings,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-18 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and interview, it was determined that the facility failed to ensure that a resident was free from abuse. This was evident for 1 of several observations made on the first floor pine view unit during an annual survey.The findings include:On 07/15/2025 at 9:59 AM, an observation on the first floor pine view unit revealed Resident #43 had his/her room call light on. On 07/15/2025 at 10:03 AM, further observation revealed Geriatric Nursing Assistant (Staff #6) walk into Resident #43's room. At the same time, the surveyor overheard Staff #6 indicate that he/she had just used the restroom with therapy. The surveyor then observed Staff #6 walk out of Resident #43's room.On 07/15/2025 at 10:08 AM, an interview with Resident #43 revealed that he/she needed to use the restroom, but no one would take her. On 07/15/2025 at 10:51 AM, an interview with Staff #6 revealed that the resident often would put his/her call light on to use the restroom, but then would not actually go. She further said that therapy services had just left the room and took the resident to use the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-18 · tag F0628 — isolatedProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that written notification of transfer was provided to the resident and or resident representative upon transfer and failed to ensure the comprehensive care plan goals were sent with the resident upon transfer. This was evident for 1 (Resident #46) of 1 resident reviewed for hospitalizations during an annual survey.The findings include:1a) On 07/16/2025 at 8:55 AM, review of Resident #46's medical record revealed he/she was hospitalized on [DATE].On 07/16/2025 at 9:38 AM, an interview with Registered Nurse (Staff #5) revealed that verbal notice of reasoning for transfer was given to the resident or representative, and that it was not in written form.On 07/16/2025 at 10:52 AM, the facility was unable to provide documentation that written notification of transfer with reasoning was provided to the resident and the resident representative. The concern was reviewed with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-07-18 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
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 code the resident's status accurately on the Minimum Data Set (MDS). This was evident for 1 (Resident #5) of 11 residents reviewed for accuracy of assessment. The findings include:The MDS is a federally mandated assessment tool that helps nursing home staff members gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need.Benign Prostatic Hyperplasia (BPH), also known as an enlarged prostate is a common condition in older men where the prostate gland grows larger, potentially causing urinary problems by pressing on the urethraOn 7/16/2025 at 10:05 AM A review of Resident #5's medical record was conducted. The review revealed that the resident was admitted into the facility on 2/3/25. The resident's hospital discharge notes dated 1/21/25 indicated that the resident had BPH as an active diagnosis. Further review of Resident #5's MDS section I…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-18 · tag F0658 — failed to meet professional standards of care — isolatedEnsure 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 observation, interview, and record review, it was determined that the facility failed to maintain professional standards of practice related to 1. documentation of treatment administration and 2. documentation of a resident's current diagnosis. This was evident for 3 (Resident #8, #3, #50) out of 12 residents reviewed during the annual recertification survey.The findings include: 1a. On 07/16/2025 at 9:23 AM, review of Resident #8’s medical record revealed an active order for hipsters (cushion belt to protect hips) to be worn at all times. On 07/16/2025 at 9:30 AM, an observation of Resident #8 revealed the resident was in their room recliner eating breakfast, but failed to reveal the hipster brace was on. On 07/16/2025 at 9:44 AM, an interview with Registered Nurse (Staff #5) revealed that the resident was supposed to wear the hipster brace at all times, but that he/she refused it that morning and it would be put on at a later time. On 07/16/2025 at 9:46 AM, review of the administration record for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-18 · tag F0690 — failed to manage incontinence, catheters, and urinary infections — isolatedProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, review of the medical record and interview with staff it was determined the facility staff failed to provide appropriate care for a resident with an indwelling urinary catheter. This was evident for 1 (Resident #5) of 2 residents reviewed for urinary catheter.The findings include:An indwelling urinary also known as a foley catheter, is a flexible tube inserted into the bladder to drain urine. It's held in place by a balloon inflated in the bladder. Indwelling catheters are used when patients are unable to urinate naturally due to various medical conditions. Foley Catheters are associated with an increased risk of urinary tract infection and therefore, proper catheter care and monitoring is crucial to avoid poor health outcomes.On 7/15/2025 at 8:16 AM Resident #5 was observed with a foley catheter. The catheter tube had cloudy urine draining. Additionally, the foley catheter bag had no date of when it was last changed.On 7/16/2025 at 10:16 AM A review of Resident #5's medical record was conducted. The review revealed a progress note dated 7/9/25 that indicated…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-18 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide 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, record reviews and interviews, it was determined that the facility failed to change the humidification bottle for a resident who is on continuous oxygen therapy. This was evident for 1 (Resident #11) of 2 residents reviewed for respiratory care.The findings include:On 7/15/2025 at 9:07 AM surveyor observed Resident #11 on 3L of oxygen via nasal cannula. The humidification bottle was dated 7/7/25.On 7/15/2025 at 12:41 PM A review of record revealed that Resident #11 had a history of pulmonary fibrosis and required continuous oxygen therapy. The review also revealed an order to change oxygen humidification bottle every night shift, every Sun for respiratory comfort per manufacturers recommendation. Further review of records revealed a care plan for altered respiratory status related to pulmonary fibrosis with an intervention that stated, Oxygen per MD orders. On 7/15/2025 at 1:12 PM Another observation was made by the Surveyor and Staff #4 who confirmed that the humidification bottle was dated for 7/7/25. On 7/15/2025 at 1:14 PM A brief interview with Staff #4…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-07-18 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure 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 — an excerpt from the official record, may be distressing
Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that all Medication Regimen Review (MRR) recommendations were addressed by the physician and that medications were adjusted when a recommendation was accepted. This was evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications during an annual survey.The findings include:A MRR is completed monthly by a pharmacist to ensure that each resident's medications that they take are safe (including the amount of the medication and the reason for it, along with making sure the medications do not have a negative effect being taken with other medications). The physician reviews the recommendations and decides whether they want to adjust the medications, or not.1a) On 07/16/2025 at 7:42 AM, review of Resident #7's medical record revealed an MRR document dated 2/7/25 which indicated the resident was on several medications that increase the risk for falls and fractures, and listed the medications. Further review of the MRR 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.
Show the remaining 21 citations
- Potential for harm · Dcited before2025-07-18 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — the official record, unedited, may be distressing
Number of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to report an allegation of abuse in a timely manner. This was evident for 1 (Incident #358045) of 9 Facility Reported Incidents (FRIs) reviewed during an annual survey.The findings include:On 7/17/25 at 10:35 AM, review of investigation documentation provided by the facility revealed that Resident #2 informed Occupational Therapist (Staff #14) on 4/4/25 at 9:12 AM that a care giver the evening prior was rough with him/her and in result caused his/her knees pain.On 7/17/25 at 10:37 AM, further review of the investigation documentation revealed that the facility failed to report the incident to the Office of Health Care Quality until 4/4/25 at 5:07 PM.On 7/18/25 at 10:57 AM, an interview with the Nursing Home Administrator revealed he was unaware that the facility needed to report all allegations of abuse within two hours. The surveyor reviewed the concern with the Nursing Home Administrator.
- Potential for harm · Fcited before2022-06-02 · tag F0880 — failed to prevent and control infections — widespreadProvide 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 surveyor observation, interviews, and reviews of the facility medication administration policy, it was determined that the facility staff failed to follow (1) the infection prevention and control program by failing to dispense medications without touching with bare hands. This was evident for 2 (Resident #31, #39) of 4 residents observed during the Long -Term Care Survey Process (LTCSP) medication pass task during an annual recertification survey. Additionally, (2) it was determined that the facility failed to have an effective system in place to help prevent the development and transmission of disease by failing to follow infection control guidelines during the laundry process. This was evident for random observations made during the tour of the facility. This deficient practice has potential to affect all residents. This deficient practice has the potential to affect all residents, staff, and visitors in the facility. The findings include: 1). On 05/19/22 at 08:50 AM, LPN #4 administered medication to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2022-06-02 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on facility-reported incidents, observations, resident interview, and reviews of the facility call bell policy, it was determined the facility staff failed to ensure access to the nurse call bell and telephone for a resident. This was evident for 1 (Resident #31) of 6 residents reviewed during the initial tour and observations of the facility during the initial stages of the Long Term Care Survey Process (LTCSP) recertification survey. The findings include: A call bell is a bedside button tethered to the wall in the resident's room, which directs signals to the nursing station; a call light usually indicates that the patient has a need or perceived need requiring attention from the nurse or geriatric nursing assistant (GNA) on duty. Reviews of facility reported incidents MD00131884 and MD00165543, on 05/19/22 revealed allegations reported to the facility administration that 1) staff take away my call light at night, and 2) a resident had the inability to reach the call light at night. During an observation of the second-floor nursing unit on 05/19/22 at 8:50 AM, the nurse…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2022-06-02 · tag F0656 — failed to write and follow a full care plan — patternDevelop 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 the review of the medical record, interviews with staff, and review of the facility policy, it was determined that the facility staff failed to develop a comprehensive care plan that included approaches for a resident that uses oxygen. This was evident for 1 (Resident #36) of 2 residents reviewed for respiratory care during the Long Term Care Survey Process (LTCSP) recertification survey. The findings include: A care plan is a written guideline of care based on the individual resident's needs developed by an interdisciplinary team that includes nursing, rehabilitation staff, and dietary staff that communicates to other health care professionals. A written care plan decreases the risk of incomplete, incorrect, or inaccurate care. In an interview with Resident #36 on 05/19/22 at 2:21 PM, Resident #36 stated that S/he uses oxygen because S/he gets short of breath. Resident #36 was observed using 2 liters of oxygen by nasal cannula at this time. A review of Resident #36's medical record on 05/19/22 at 2:21 PM revealed a physician's order, dated 01/17/22, that instructed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-02 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation and reviews of the facility policy, it was determined that the facility failed to ensure each resident was treated in a dignified manner regarding urinary catheter care. The facility failed to ensure the urine collection bags had privacy covers in place. This was evident for 1 (Resident #37) of 4 residents reviewed for urinary catheters during the Long Term Care Survey Process (LTCSP) recertification survey. The findings include: During an initial tour of the facility on 05/19/22 at 8:50 AM, Resident #37 was observed sitting at the nurses' station in a wheelchair with a urine collection bag that was hooked and hanging underneath the wheelchair frame. Resident #37's urine collection bag was observed without a cover. Upon an observation of the second-floor nursing unit on 05/19/22 at 10:30 AM, Resident #37's urine collection bag was again observed without a cover. A third observation of the second-floor activity area where a group of residents were waiting for a music program to start on 05/19/22 at 1:40 PM, Resident #37's urine collection bag was again observed…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2022-06-02 · tag F0610 — failed to investigate and act on abuse reports — isolatedRespond appropriately to all alleged violations.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview and review of facility reported incident (FRI) investigation documentation, it was determined the facility staff failed to thoroughly investigate an incident of alleged employee to resident abuse. This was evident for 1 of 12 residents (Resident # 6) reviewed for abuse during this survey. The findings include: On 5/25/2022, at 9:30 AM, review of the record of the facility reported incident # MD00157848 revealed that Resident # 6 had alleged that GNA # 29 had picked up the fork and shoved the last bite of pie in her/his mouth during dinner. Resident #6 stated the left corner of her/his mouth was sore. Further review of the facility investigation revealed the facility was not able to substantiate the allegation of abuse. However, there was no statement or record of interviews of other residents for whom the accused employee provided care or services. On 5/31/2022, at 11:33 AM, in an interview with the Registered Nurse (RN #6) to whom the resident had reported the incident, she/he stated they did not have any recollection of the details of the incident. RN #6 further…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2022-06-02 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 review of resident medical record, review of a facility reported incident, staff interviews, and review of the facility ambulation and transfer policy, it was determined that 2 GNA staff members failed to follow the Resident #35's care plan and transfer the resident with a mechanical lift. This was evident for 1 (Resident #35) of 26 facility-reported incidents reviewed during the Long Term Care Survey Process of an annual recertification survey. The findings include: An insufficiency fracture is defined as a stress fracture occurring in abnormal bone (e.g., osteoporotic bone) subjected to normal forces. By way of history, according to Resident #35's medical record, Resident #35 suffers from progressive dementia, adult failure to thrive, chronic kidney disease, osteoporosis, osteoarthritis, and is currently receiving Hospice benefits. The Resident is pleasantly confused and totally dependent on staff for all aspects of care. Resident #35 is a centenarian. A review of the facility-reported incident MD00176846, on 05/25/22, revealed an allegation that Resident #35 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2018-11-15 · tag F0726 — failed to have competent, trained nursing staff — patternEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on staff interview and documentation review it was determined that facility staff failed to provide evidence that the facility's Certified Medicine Aide's (CMA) have been deemed competent to administer medications independently. This is true for 7 CMA's (Staff #3, #4; #10; #11; #12; #13; #14) employed by this facility. Findings include: On 11/13/18 review of the employee files for CMA Staff #3; #4; #10; #11; #12; #13 and #14 failed to reveal evidence that they had been observed by a nurse and deemed competent to administer medications independently. On 11/13/18 at 11:25 AM the Director of Nursing (DON) was asked to provide the CMA Orientation Skills Competency sheets for all CMA's employed by the facility. CMA Staff # 3 was observed during medication pass, administering medications to residents independently. In an interview with Staff #3 on 11/14/18 who began her employment on 10/8/18 revealed that she has been oriented by 2 other CMA's. She had an incomplete CMA Orientation Skills Competency check off sheet in her possession, that was checked off for some skills but there…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-11-15 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on reviews of administrative documents and staff interview, it was determined that a facility staff member failed to report an allegation of physical abuse immediately to the facility administrator and initiate an investigation into the allegation of abuse. This was evident for 1 of 5 residents (Resident #405) reviewed for abuse during an annual re-certification survey. The findings include: Review of facility reported incident MD00124575 on 11/09/18 revealed an allegation Resident #405 was allegedly abused by an unknown staff member on an unknown date. In an interview with Dietary Aide #1 on 11/08/18 at 2:42 PM, dietary aide stated that s/he witnessed finger prints and a palm print to Resident #405's arm during the morning of Saturday, 03/10/18 at approximately 7 AM. Dietary Aide #1 stated s/he immediately told Resident #405's Geriatric Nursing Assistant about the finger and palm prints to Resident #405's arm. Further review of the facility investigation revealed that the allegation of alleged abuse to Resident #405 was not immediately brought to the attention of the facility…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-15 · tag F0623 — isolatedProvide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, it was determined that the facility failed to notify a resident in writing of the reason for a hospital transfer in language that was clear and understandable. This was evident for 1 of 2 residents (Resident #41) investigated for hospitalizations. The findings include: On 11-5-18 Resident #41 who is oriented to person, place and time was transferred to the hospital. Review of the medical record revealed the hospitalization notification form was not completed. Interview with the interim Administrator revealed on 11-8-18 at 2:30 PM they did not know if the notification was given to Resident #41. On 11-9-18 at 8:30 AM the interim Administrator stated the written notification was given to Resident #41's daughter on 11-8-18 when they came in to the facility to collect Resident #41's belongings. As a result Resident #41 did not receive a written notice. Review of the written notification given to the daughter revealed the notice stated the reason for transfer was altered mental status but did not explain the term in manner a layperson would…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-11-15 · tag F0641 — isolatedEnsure each resident receives an accurate assessment.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and staff interview it was determined the facility staff failed to document accurate assessments for a resident on the Minimum Data Set (MDS). This was evident for 1 of 37 residents (Resident #53) selected for review during the survey process. The findings include: The MDS is a federally-mandated assessment tool that helps nursing home staff gathers information on each resident's strengths and needs. Information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. Categories of MDS (Minimum Data Set) are: Cognitive patterns, Communication and hearing patterns, Vision patterns, Physical functioning and structural problems which includes the assessment of range of motion, Continence, Psychosocial well-being, Mood and behavior patterns, Activity pursuit patterns, Disease diagnosis, Other health conditions, Oral/nutritional status, Oral/dental status, Skin condition, Medication use and Treatments and procedures. At the end of the MDS assessment the interdisciplinary team…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-11-15 · tag F0656 — failed to write and follow a full care plan — isolatedDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on reviews of a closed medical record, it was determined that the facility staff failed to follow a resident's care plan and document a pain assessment. This was evident for 1 of 3 residents (Resident #256) reviewed for pain management during an annual re-certification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Review of Resident #256's pain management care plan revealed a nursing intervention to rate Resident #256's pain by using the facility pain scale before administering pain relieving medication. Review of Resident #256's closed medical record on 11/08/18 revealed a physician order, dated 10/31/17, instructing the nursing staff to administer a narcotic medication every 3 hours as needed for pain. On 11/06/17, Resident #256's attending physician discontinued the previous physician order for the narcotic medication and wrote a new physician order to administer the narcotic pain medication at 8 AM, 2 PM and 8 PM. 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.
- Potential for harm · Dcited before2018-11-15 · tag F0684 — failed to provide proper treatment and quality of care — isolatedProvide 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 record review, observation and interview, it was determined the facility failed ensure a resident received proper and timely care (Resident #4) and failed to follow physicians' orders for 3 residents (Resident #56, #46, #41). This was evident for 4 of 37 residents reviewed during the survey process. The finding includes: 1. Medical record review for Resident #56 revealed a 7/27/18 physicians' order: Discontinue Vital signs every shift and discontinue weights every week. Further, record review of staff documentation revealed the facility staff failed to follow the physician order and continued to take Resident #56's blood pressure from July 28, 2018 through August 10, 2018. Interview with the Director of Nursing on 11/8/18 at 10:50 AM confirmed the facility staff failed to follow the physician order for Resident #56. 2. Medical record review for Resident #46 revealed on 10/11/18 the physician ordered: anti-embolism stockings on in morning and off at bedtime. Anti-embolism (compression) stockings improve blood flow in the legs. Compression stockings gently squeeze the legs to…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-15 · tag F0697 — failed to manage pain — isolatedProvide 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 reviews of a closed medical record, it was determined that the facility staff failed to take steps to address a resident's complaint of pain. This was evident for 1 of 3 residents (Resident #256) reviewed for pain management during an annual re-certification survey. The findings include: Review of Resident #256's closed medical record on 11/08/18 revealed a physician order, dated 10/31/17, instructing the nursing staff to administer a narcotic medication every 3 hours as needed for pain. On 11/06/17, Resident #256's attending physician discontinued the previous physician order for the narcotic pain medication and wrote a new physician order to administer the narcotic pain at 8 AM, 2 PM and 8 PM. Further review of Resident #256's closed medical record revealed a nurse's note, dated 11/10/17 at 4:51 PM, indicating Resident #256 complained of pain on 11/10/17 at 2 AM and the night nurse explained that s/he was unable to administer a dose of the narcotic pain medication Resident #256. The 11/10/17 night nurse documented that s/he had to wait until the morning. 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.
- Potential for harm · D2018-11-15 · tag F0725 — failed to have enough nursing staff — isolatedProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on resident interviews, staff interviews, and a review of the resident council meeting notes it was determined that the facility staff failed to provide sufficient staff to respond to call lights and address resident concerns. The findings include: A meeting was held a meeting with members of the Resident Council as part of the survey process on 11/9/18 at 9:30 AM. During this meeting the residents all shared concerns with staff not responding to the call lights in a consistently timely manner and when they do respond they sometimes make the residents wait until the concerns are addressed. Residents said they have 3 Geriatric Nursing Assistants (GNA) for the whole floor and sometimes less during night shift. Residents also stated that there are as many as 28 residents who need 2 GNA's to get in and out of bed as well as their wheelchairs. This leaves 1 GNA to assist every other resident whenever a resident needs to transfer. The evening shift will not assist between 3:00 PM and 3:45 PM because they are getting report. One staff member monitors for call lights during this time…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-15 · tag F0730 — isolatedObserve each nurse aide's job performance and give regular training.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of employee files and staff interview, it was determined that the facility failed to perform annual performance reviews for some of the geriatric nursing assistants (GNA). This was identified for 3 of 5 GNA staff members (GNA #3, #4, #5) reviewed during an annual re-certification survey. The findings include: 1) Review of GNA #3's employee and education records revealed GNA #3's last performance evaluation was conducted on 02/28/2017. 2) Review of GNA #4's employee and education records revealed GNA #4's last performance evaluation was conducted on 04/21/2017. 3) Review of GNA#5's employee and education records revealed GNA #5's last performance evaluation was conducted on 05/17/2017. In an interview with the facility administrator on 11/09/18 at 2:24 PM, the facility administrator confirmed that the facility had not conducted a yearly performance evaluation for GNA #3, #4 and #5.
- Potential for harm · D2018-11-15 · tag F0759 — failed to keep medication error rate low — isolatedEnsure 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 during medication pass it was determined that facility staff failed to administer medications with less than a 5% medication error rate. This was true for 1 out of 25 medication administration observations. The findings include: 1. On 11/09/18 at 9:12 AM during medication pass Certified Medicine Aide (CMA) Staff #3 was observed administering medications to Resident #8. When giving the medications, Resident #8 asked Staff #3 what the medications were and what they were for. Staff #3 was unable to identify any of the medications being given and was unable to tell Resident #8 why s/he was taking any of the medications. 2. On 11/09/18 at 9:12 AM during medication pass Certified Medicine Aide (CMA) Staff #3 was observed administering medications to Resident #8. Staff #3 was observed leaving the residents room without observing Resident #8 take the prepared Healthy Lax 17 grams (laxative). The medication was left on the over bed table. Staff #3 was made aware of this concern immediately by the surveyor and returned to Resident #8 to administer the medication. The…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-15 · tag F0761 — failed to label and store drugs safely — isolatedEnsure 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 observation and staff interview it was determined the facility staff failed to dispose of expired medical supplies on 1 of 2 nursing units observed (Nursing Unit 1). The findings include: 1. Observation was made on [DATE] at 2:22 PM of the medication room on Nursing Unit 1. One Provent Arterial Blood sampling kit expired 07/2018; 14 Vacuette red top containers with an expiration date of 9/2018 and 13 packets with 3 per packet of lemon glycerin swab sticks which expired 08/2017. Licensed Practical Nurse (LPN) Staff #1 was present and immediately made aware of the expired supplies. 2. When walking down the long hall of unit 1 surveyor observed an unattended medication cart that was left unlocked. Surveyor was able to verify by opening the drawers of the medication cart. After being notified of surveyor's presence, Registered Nurse Staff #1 returned to the cart and then locked the medication cart. LPN Staff #1 was also present and made aware of this concern. The Administrator and the Director of Nursing…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-11-15 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure 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 it was determined the facility staff was not conducting themselves in a manner that would maintain sanitary conditions by not following accepted personal cleanliness techniques. The facility staff also failed to maintain food service equipment in a manner that ensures sanitary food distribution. This was evident during the initial tour of the kitchen and follow-up visits at satellite kitchens during the annual survey. The findings include: 1. The handwashing sink by the dishwasher had an empty soap dispenser for hand washing and no paper towels for drying the hands. 2. The dishwasher, Staff #7 was not wearing gloves he/she moved to the pot washing sink and handled and scrub several different pieces of soiled food service equipment and then returned to the dishwasher and removed clean food service equipment. During that time, she/he did not wash his/her hands. 3. While preparing resident lunch trays Staff #4 failed to cover all hair with the required hairnet. All nursing care facilities must assure that food be stored, prepared and served under sanitary…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2018-11-15 · tag F0835 — failed to run the facility competently — isolatedAdminister the facility in a manner that enables it to use its resources effectively and efficiently.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on record review and interview it was determined that facility staff failed to provide an accurate and complete Matrix, as requested by the survey team at the beginning of the annual re-certification survey. The findings include: The Matrix is a document used to identify pertinent care categories for: newly admitted residents within the last 30 days who still reside in the facility, and all other residents. The facility provides the resident name, room number and makes available specific information as requested for each resident. The Matrix requires information regarding: Dementia/Alzheimer's; Specific medications; Facility acquired pressure ulcers; Worsening Pressure Ulcers; Excessive weight Loss; Tube Feeing; Dehydration; Residents with Physical Restraints; Falls and Falls with Injury; Residents receiving Dialysis; Residents receiving Hospice services; Residents receiving End of Life Comfort Care; Residents with a Tracheostomy; Residents on Ventilator; Residents with Transmission-Based Precautions; Intravenous Therapy and Residents with Infections. On 11/7/18 during the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2018-11-15 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — the official record, unedited, may be distressing
Based on observation and staff interview it was determined that the facility staff failed to provide safe and sanitary conditions to prevent the development and transmission of disease and infection. This was evident during observation of 1 of 25 medication passes. The findings include: On 11/9/18 at 9:12 AM during medication pass Certified Medicine Aide (CMA) Staff # 3 was preparing Healthy Lax 17 grams (a laxative) and did not have scissors to open the packet. She asked another staff member for scissors who retrieved a pair out of a pouch around her waist. CMA Staff #3 did not clean the scissors before cutting the medication packet. Staff #3 was made aware of the concern of possible contamination at the time of the occurrence. The Director of Nursing and The Administrator were made aware of this concern on 11/9/18 at 1:58 PM
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to ACTS RETIREMENT-LIFE COMMUNITIES — 27 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 →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.7 | -0.7 vs chain |
| Health inspection | 3 of 5 | 4.4 | -1.4 vs chain |
| Staffing | 5 of 5 | 4.9 | ≈ chain avg |
| Quality measures | 3 of 5 | 4.4 | -1.4 vs chain |
The other 26 homes this chain runs (chain average 4.7★, 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 / manager | Type | Role | Since |
|---|---|---|---|
| ACTS ACQUISITION AND DEVELOPMENT COMPANY LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| ACTS ALLIANCE MANAGEMENT LLC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| ACTS LEGACY FOUNDATION, INC. | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| ACTS MANAGEMENT SERVICES, INC. | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/31/2025 |
| ACTS RETIREMENT SERVICES, INC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| ACTS RETIREMENT-LIFE COMMUNITIES MANAGEMENT, LLC | Organization | INDIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/31/2025 |
| ACTS SIGNATURE COMMUNITY SERVICES INC | Organization | INDIRECT OWNERSHIP INTEREST | since 12/31/2022 |
| BONITA SPRINGS RETIREMENT VILLAGE INC | Organization | INDIRECT OWNERSHIP INTEREST | since 11/01/2024 |
| MEASE LIFE INC | Organization | INDIRECT OWNERSHIP INTEREST | since 10/01/2023 |
| ACTS COMMUNITIES OF MARYLAND, INC. | Organization | 5% OR GREATER MORTGAGE INTEREST; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 12/31/2022 |
| AHERN, SUSAN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| CHRISTIANSEN, KAREN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| FOX, GLENN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| GRANT, GERALD | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| GRANT, JONATHAN | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| VALDIVIA, PEGGY | Individual | MANAGING CONTROL - GOVERNING BODY; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| DETWEILER, HAROLD | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| FORREST, ANNE | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| KELLY, MICHAEL | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| LAWSON, DANIEL | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| NEARY, ANNE | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| PAQUETTE, ELLEN | Individual | CORPORATE DIRECTOR | since 01/01/2025 |
| ATHEN, MICHAEL | Individual | OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2025 |
| U.S. BANK | Organization | TRUSTEE OF THE SNF; ADP OF THE SNF | since 07/09/2025 |
| BAKER TILLY ADVISORY GROUP LP | Organization | ADP OF THE SNF | since 02/03/2025 |
| BAKER TILLY US LLP | Organization | ADP OF THE SNF | since 11/05/2024 |
| LAKHANI, TASNEEM | Individual | ADP OF THE SNF | since 01/01/2025 |
CMS files one row per role, so the 55 rows in the source record cover these 27 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.
13 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.
This home reported $1.1M paid to related parties (affiliated landlords or management companies) in its most recent cost report.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
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
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.
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 215130. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-07-18, 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.