Pickersgill Retirement Community
615 Chestnut Avenue, Towson, MD 21204 · Non profit - Corporation · 43 certified beds · (410) 825-7423 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- 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)
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- a high number of inspection citations overall (20) — 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.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 3 of 5 |
Location & what’s nearby
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 | 1 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 fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
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 | 26.7% | 20.4% | 15.4% | worse |
| Long-stay residents who lose too much weight | 15.4% | 5.4% | 5.4% | worse |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.5% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.6% | 1.5% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 0.9% | 22.8% | 6.5% | better than state‡ — see note marked double-dagger 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 | 13.0% | 2.4% | 3.3% | worse |
| Long-stay residents whose ability to walk worsened | 24.7% | 22.2% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 16.0% | 16.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 97.0% | 96.6% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 10.0% | 5.9% | 4.7% | worse |
| Long-stay residents with worsening bladder/bowel control | 22.5% | 25.0% | 21.2% | typical |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 25.0% | 13.8% | 17.1% | worse |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.1% | 1.4% | better |
| Short-stay residents rehospitalized after admission | 15.4% | 21.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 4.2% | 9.8% | 12.0% | better |
| Long-stay hospitalizations per 1,000 resident days | 1.89 | 1.33 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 2.01 | 1.20 | 1.80 | worse |
‡ 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.
49.7% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 39 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 54.5% 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 33 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: not reported. This home filed no therapist hours at all in its payroll data for this quarter. That is a gap in what it reported, and we do not read it as an absence of therapy — the homes that file nothing here include ones that discharged hundreds of Medicare rehab patients in the very same period, who plainly received therapy from someone. Because we cannot tell a home that under-reports from one that genuinely provides little, this home is left out of the comparison above rather than scored at zero. Ask it directly how many therapist hours a rehab resident gets, and on which days.
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 | 49.7%CMS range 38.2–65.1 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.3%CMS range 6.5–16.7 | 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 | 54.5% | 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 | 42.4% | 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 | 39.4% | 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 | 94.7% | 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 | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 5.3% | 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 | 2.6% | 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 | 6.7%CMS range 3.5–12.0 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 1.22 | 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 43 beds and averages 31.4 residents a day — about 73% occupied, or roughly 12 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 5.43 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 1.24 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.01 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 3.85 hrs/resident/day on weekends vs 6.08 on weekdays — 37% thinner on weekends — a notable drop. RN hours go from 1.46 to 0.69 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
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 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.
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.
20 citations, most serious first. The 10 most serious are shown; the remaining 10 are one tap away and print in full.
- Potential for harm · Ecited before2026-04-10 · tag F0812 — failed to store, cook, and serve food safely — patternProcure 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, interview and record review, it was determined the facility failed to:1. Follow professional standards for food service safety, evident for 1 of 1 emergency water supply, and 3 out of 3 food storage bins reviewed. 2. Ensure a drain was maintained sanitarily. This was evident for 1 out of 2 drains located near the facility's dishwasher.Observations made during the surveyor's review of the kitchen task during the facility's recertification survey.The findings include:On 4/7/26 beginning at 8:55AM the surveyor conducted an initial tour of the facility's kitchen.On 4/7/26 at 9:00AM the surveyor conducted a dual observation of three storage bins each separately storing the following loose food items: panko bread crumbs, flour, and sugar, with the facility's Director of Dining Services (DDS) #10. The exterior surface of the bread crumb bin was observed to have an unclean, greasy, crusty appearance with visible tan food debris present on the exterior. Upon the removal of the lid, the interior surface near the top rim of the container was observed with brown food…
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 · E2026-04-10 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review it was determined the facility failed to ensure the environment was free from pests. This was evident for 1 out of 1 nursing unit during the surveyor's review of Complaint #2714168 and during the facility's recertification survey.The findings include:On 4/7/26 at 7:35AM the surveyor conducted a review of Complaint #2714168 which documented the complainant's concern for mice pest presence in Resident #13's room located on the facility's nursing unit. During multiple surveyor's subsequent tours of the facility's nursing unit, various pest control devices including bait stations, traps and other methods of pest control were observed to be present. Multiple traps were observed by surveyors to be present in various Resident rooms. On 4/8/26 at 12:22PM the surveyor conducted an interview of Director of Maintenance #11 who acknowledged that the facility has had mice on the long term care unit and also reported that the facility had increased the amount of exterminators…
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 · D2026-04-10 · 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 Based on record reviews and staff interviews, it was determined that the facility failed to provide documentation that indicates that the facility provided the receiving hospital with the resident's information prior to transferring the resident to the hospital. This was evident for 1 (Resident #33) out of 4 residents reviewed during an annual recertification survey for hospitalizations and discharges.The findings include:On 4/8/26 at 1:51 PM, the surveyor conducted a record review. The record review revealed that Resident #33 was hospitalized on [DATE].On 4/9/26 at 9:59 AM, the surveyor interviewed the Director of Nursing (DON) #2. The surveyor asked DON #2 to provide documentation indicating that the facility provided the receiving hospital with Resident #33's information prior to transferring Resident #33 to the hospital. DON #2 indicated that she would check Resident #33's medical record.On 4/9/26 at 10:32 AM, DON #2 stated that when the emergency medical technicians arrive at the facility to transport 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 · Dcited before2026-04-10 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review it was determined the facility failed to ensure documentation of medication side effect monitoring, and maintain medical records in accordance with accepted professional standards and practices. This was evident for 2 (#9, #17) of 5 residents reviewed for unnecessary medications.The findings include:1. On 4/7/26 at 3:21PM the surveyor conducted an unnecessary medications review for Resident #9 at which time the surveyor reviewed the medical record which revealed the following information: -Resident #9 was admitted to the facility on [DATE] -Resident #9 was observed to have an active medical order dated as beginning on 4/22/25 for Mirtzapine medication for indication of depression. -No side effect or behavior monitoring for psychotropic medications by licensed nursing staff was observed consistently documented in the medical record. On 4/7/26 at 3:33PM the surveyor conducted an interview of the facility's Director of Nursing (DON) and inquired as to how the nursing staff…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-01-31 · 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
Based on observations and interviews, it was determined that the facility staff failed to ensure canned goods and dry food were labeled with expiration dates and failed to label opened food with a used by date. This deficient practice was evident during the kitchen observation and has the ability to impact all residents who receive food from the kitchen. The findings include: On 01/29/25 at 10:33 AM, during an initial tour of the facility's kitchen with the Director of Dietary Services (DDS) #24 and Dietary Chef #25, the surveyor observed a rack of canned goods without an expiration date. When asked about the process for determining when to discard outdated canned goods the DDS #24 stated they were unsure and deferred the question to the Kitchen Chef #25. The Kitchen Chef #25 explained that can goods are ordered frequently, but the kitchen does not have a process in place to track expiration or best by date for canned goods. Next to the canned good rack, the surveyor along with the DDS #24, and Dietary Chef #25 observed an open cardboard box of Kellogg's Club Crackers containing…
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 · E2025-01-31 · tag F0550 — failed to protect resident dignity and rights — patternHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, it was determined that the facility failed to ensure residents were treated with dignity and respect. This was evident during observation of 19 rooms on 1 unit (Decker Unit) during the survey. The findings include: On 01/29/25 at 08:16 AM, the initial observation of the facility revealed rooms 406, 413, 416, 418, 419, 420, 421, 422, 424, 425, 426, 427, 428, 429, 430, 431, 432, 434, 435, which had over-the-door organizers on the outside of the doors. The organizers contained various resident care items, including briefs. On 01/31/25 at 08:15 AM, an interview with Resident #28, who resided in room [ROOM NUMBER], revealed that he/she did not know why the organizers were on the outside of the resident room door and was unhappy about it due to a privacy concern. On 01/31/25 at 2:05 PM, at the time of exit, the surveyor reviewed the concern regarding the failure to ensure residents are treated with dignity and respect.
- Potential for harm · D2025-01-31 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
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 a resident's medical record was protected from public view. This was evident for 1 of 2 medication carts (400 hallway medication cart) observed during the survey. The findings include: On 01/30/25 at 07:57 AM, an observation on the Decker Unit revealed a medication cart on the 400 hallway which revealed a computer screen open with Resident #21's name, date of birth , and Medication Administration Record (MAR). The same medication cart which the computer was on was unlocked, which would allow anyone to open medication cart drawers with several resident medications inside. On 01/30/25 at 08:00 AM, an observation revealed Registered Nurse Supervisor (RN #22) walked up to the medication cart and closed out of the screen which was revealing Resident #21's information and locked the cart. The surveyor approached RN #22 and asked if she was assigned to the medication cart at the time, she indicated yes. On 01/30/25 at 8:00 AM, an interview with RN #22 revealed that the expectation was for nurses 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 · D2025-01-31 · 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 reviews and interviews, it was determined that facility staff failed to update the residents' (#8) Minimum Data Set to accurately reflect the resident's medical condition, and failed to code the residents' (#16, #31) status accurately on the Minimum Data Set (MDS) assessment. This occurred for 3 (#8, #16, #31) out of 3 residents reviewed during the annual survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff 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. The Assessment Reference Date (ARD) is the specific end point of look-back periods of resident status for the MDS assessment process. 1) On 01/31/25 at 7:38 AM, a review of Resident #8's treatment administration record for December 2024 revealed an order to apply Optifoam (foam wound dressing) pad to sacrum topically every day. The treatment order start date was 12/03/2024 at 7:00…
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 before2025-01-31 · 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 and staff interview, the facility failed to ensure a resident received care based on professional standards. This was evident for 1 (Resident #16) of 2 residents reviewed for skin conditions. The findings include: On 01/29/25 at 08:18 AM, an initial observation of Resident #16 revealed a small bruise-like area on the his/her left clavicle. On 01/30/25 at 10:21 AM, review of Resident #16's medical record failed to reveal documentation indicating the skin condition was identified. On 01/30/25 12:17 PM, an interview with the Quality Assurance Nurse (Staff #20) revealed that she was assigned to Resident #16. She indicated she was not aware of Resident #16's current skin conditions. The surveyor and Staff #20 walked to the residents room and the surveyor pointed out the area of concern on his/her left clavicle. Staff #20 said that the resident has ecchymosis. On 01/30/25 at 12:20 PM, the surveyor requested documentation of Resident #16's weekly skin checks from Staff #20. On 01/30/25 at 12:27 PM, an interview with the Unit Manager (Staff #5) revealed that the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-01-31 · 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
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview with facility staff, it was determined that the facility failed to ensure that a resident receiving oxygen therapy had orders that were being followed and failed to post cautionary signs indicating the use of oxygen. This was evident for 1 (Resident #31) of 1 resident reviewed for respiratory care, and 1 (Resident #9 and #31) of 2 residents observed receiving oxygen. The findings include: 1) On 01/29/25 at 08:14 AM, an initial observation of Resident #31 revealed she/he was on oxygen by nasal cannula. The oxygen level was at 3.5 liters/minute. The nasal cannula was dated 1/27/25. A nasal cannula is a small, flexible tube that fits inside both nostrils, delivering supplemental oxygen directly into your nose. Oxygen liter refers to the amount of oxygen a person receives per minute, measured in liters, and is essentially how much supplemental oxygen is being delivered to them through a piece of oxygen supplying equipment. On 01/29/25 at 02:33 PM, review of Resident #31's medical…
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 10 citations
- Potential for harm · D2025-01-31 · tag F0700 — isolatedTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent and document alternatives attempted prior to the initiation of bed rails. This was evident for 2 (Resident #31 and #13) of 2 residents reviewed for accident hazards. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. The facility should obtain a signed consent form before the use of bedrails. 1) On 01/29/25 at 08:14 AM, during the initial phase of the survey, the surveyor observed Resident #31 in bed with two 1/4 bed rails up on either side of the top end of the bed. On 01/30/25 at 09:37 AM, an interview with the Director of Rehabilitation (Staff #16), revealed that Resident #31 was from assisted living and had not been on case load and was unable…
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 · D2025-01-31 · 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 interview, it was determined that the facility failed to ensure staff received annual performance reviews. This was evident for 4 of 5 GNAs (GNA#7, GNA #19, GNA #21, and GNA #26) reviewed during the annual survey. The findings include: On 01/30/24 at 4:00 PM, the surveyor requested documentation of annual performance reviews for the last two years (2023 and 2024) for GNA #7, GNA #19, GNA #21, and GNA #26. On 01/31/25 at 10:10 AM, an interview with the Director of Nursing (DON) revealed that the facility was unable to provide the documentation requested by the surveyor because the facility was not in compliance with annual performance reviews for GNA #7, GNA #19, GNA #21, and GNA #26.
- Potential for harm · D2025-01-31 · 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, record review, and interview, it was determined that the facility failed to have a medication error rate of less than 5% during medication administration observation. This was evident for 3 (Resident #9, #16, and #236) of 26 medication administration opportunities which resulted in a medication error rate of 11.54%. The findings include: 1) On 01/30/25 at 08:02 AM, the surveyor observed Registered Nurse (RN) Supervisor #22 administer 4 medications to Resident #236. On 01/30/25 at 08:15 AM, the surveyor observed RN #22 document the medications, which revealed 5 medications being signed off as administered, which included Bicalutamide 50MG, which was not observed to be prepared or administered to Resident #236. On 01/30/25 at 08:26 AM, review of Resident #236 Medication Administration Record (MAR) revealed 5 medications signed off, including Bicalutamide Tablet 50 MG (A drug used with another drug to treat prostate cancer that has spread to other parts of the body). On 01/31/25 at 12:52 PM, the surveyor obtained a MAR audit for Resident #236, which revealed 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 · D2025-01-31 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident was free from a significant medication error. This was evident for 1 (Resident #236) of 5 resident medication administrations observed during the survey. The findings include: On 01/30/25 at 08:02 AM, the surveyor observed Registered Nurse Supervisor (RN) #22 administer 4 medications to Resident #236. On 01/30/25 at 08:15 AM, the surveyor observed RN #22 document the medications, which revealed 5 medications being signed off as administered, which included Bicalutamide 50MG, which was not observed to be prepared or administered to Resident #236. On 01/30/25 at 08:26 AM, review of Resident #236 Medication Administration Record (MAR) revealed 5 medications signed off, including Bicalutamide Tablet 50 MG (A drug used with another drug to treat prostate cancer that has spread to other parts of the body). On 01/31/25 at 12:52 PM, the surveyor obtained a MAR audit for Resident #236, which revealed the exact time that the medication was signed off, which indicated 01/30/25 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.
- Potential for harm · D2025-01-31 · tag F0909 — failed to maintain a comfortable temperature — isolatedRegularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
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 the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. This was evident for 2 (Resident #31 and #13) of 2 residents reviewed for accidents hazards. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. 1) On 01/29/25 at 08:14 AM, during the initial phase of the survey, the surveyor observed Resident #31 in bed with two 1/4 bed rails up on either side of the top end of the bed. 2) On 01/29/25 at 10:05 AM, during the initial phase of the survey, the surveyor observed Resident #13's bed in his/her room which revealed two 1/4 bed rails up on either side of the top end of the bed. On 01/30/25 at 11:17 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.
- Potential for harm · D2025-01-31 · tag F0947 — failed to train nurse aides adequately — isolatedEnsure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
What the surveyor found here — the official record, unedited, may be distressing
Based on record review and interview, it was determined that the facility failed to ensure there was a system in place to ensure Geriatric Nursing Assistants (GNAs) completed 12 hours of in-service training annually. This was evident for 3 (GNA #7, GNA #19, GNA #21) of 5 GNAs reviewed during the survey. The findings include: 1) On 01/30/25 at 3:19 PM, review of GNA #7's employee file revealed that Staff #7 received 3 hours of in-service training in 2024. 2) On 01/30/25 at 3:21 PM, review of GNA #19's employee file revealed that Staff #19 received 5 hours of in-service training in 2024. 3) On 01/30/25 at 3:24 PM, review of GNA #21's employee file revealed that Staff #21 received 0 hours of in-service training in 2024. On 01/31/25 at 10:10 AM, an interview with the Director of Nursing (DON) revealed that the facility was not in compliance with the 12 hour GNA annual in-service training for Staff #7, Staff #19, and Staff #21.
- Potential for harm · Dcited before2020-02-28 · 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 medical record review and interview, it was determined the facility staff failed to thoroughly clarify a medication order with the physician for Resident (#228). This was evident for 1 of 29 residents selected for review during the annual survey process. The findings include: Medical record review on 2/28/20 at 11:00 AM revealed on 9/27/19 the physician ordered: Hydralazine 50 milligrams by mouth 3 times a day as needed for blood pressure of systolic (top number) of above 160 or diastolic (bottom number) greater than 100. Hydralazine is used with or without other medications to treat high blood pressure. On 10/28/19 the physician ordered: Hydralazine 25 milligrams by mouth 3 times a day (not as needed but routine), hold for systolic blood pressure less than 110; however, the facility staff failed to clarify the Hydralazine order with the physician to determine if both medication orders were still valid. Interview with the medical director on 2/28/20 at 2:00 PM revealed the facility staff would not administer both ordered Hydrazine medications (as needed and routine). 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 · D2020-02-28 · 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
Based on record review, observation and staff interview, it was determined the facility staff failed to ensure the resident's environment was free from potential accidents (#12 and #14). This was evident for 2 of 2 residents selected for review of accidents and 2 of 29 residents selected for review during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments contain standardized questions about several elements of functional and cognitive status and mobility, Behavioral symptoms - a number of items about behavioral symptoms common in dementia, Psychosocial functioning - resident participation in activities and resident preferences, Symptoms and geriatric syndromes - for example pain, continence, falls, nutritional status, activities of daily living and many others 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.
- Potential for harm · D2020-02-28 · tag F0692 — failed to prevent malnutrition and dehydration — isolatedProvide enough food/fluids to maintain a resident's health.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#24) with dietary interventions as ordered by the physician. This was evident for 1 of 1 resident selected for review of nutrition care area and 1 of 29 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #24 on 2/26/20 at 10:00 AM revealed on 11/3/19 the physician in collaboration with the Speech Language Pathologist ordered: Please place one type of food for meals to increase self-feeding. Place light color foods in dark bowls and dark color foods in light bowls for visual contrast as the resident reported difficulty with eating + difficulty finding food on the plate. It was also ordered for Resident #24 to be provided a divided plate for easier access to food. A divided plate has raised walls for scooping food onto silverware for those who have limited mobility and need assistance when eating. Surveyor observation of Resident #24 on 2/26/20 at 9:00 AM, 2/27/20 at 8:19 AM and 2/27/20 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.
- Potential for harm · Dcited before2020-02-28 · tag F0842 — failed to keep accurate, complete medical records — isolatedSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record for Resident (#12) in the most accurate and complete form. This was evident for 1 of 29 residents selected for review during the annual survey. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. Medical record review on 2/27/20 at 12:00 PM for Resident #12 revealed on 4/10/19 the physician ordered: Do not weigh, as the resident was admitted to hospice services. Hospice care is a special kind of care that focuses on the quality of life for people and their caregivers who are experiencing an advanced, life-limiting illness. Hospice care provides compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible. On 12/5/19, Resident #12 was discharged from hospice services. Record review revealed the facility staff documented weights…
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.
“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.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| ALLEN, MARIA | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 04/01/2024 |
| EISNEBERG, BARRY | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 09/03/2015 |
| FLOWER, NANCY | Individual | CORPORATE DIRECTOR | since 01/01/2002 |
| GERBERG, KENNETH | Individual | CORPORATE DIRECTOR | since 04/09/2007 |
| KARPOVICH, JILL | Individual | CORPORATE DIRECTOR | since 01/01/2022 |
| KNIGHT, NICOLE | Individual | CORPORATE DIRECTOR; OPERATIONAL/MANAGERIAL CONTROL | since 05/08/2023 |
| LONG, CAROL | Individual | CORPORATE DIRECTOR | since 01/01/2013 |
| SMITH, EMILY | Individual | CORPORATE DIRECTOR | since 01/01/1999 |
| AUWAERTER, KAREN | Individual | CORPORATE OFFICER | since 01/01/2017 |
| BROOKE, ANN | Individual | CORPORATE OFFICER | since 01/01/2001 |
| CARROLL, MARSHA | Individual | CORPORATE OFFICER | since 01/01/2013 |
| FINNEGAN, FRAN | Individual | CORPORATE OFFICER | since 01/01/2013 |
| FORSTER, KRISTEN | Individual | CORPORATE OFFICER | since 01/01/2021 |
| HUGHES, WINNIE | Individual | CORPORATE OFFICER | since 01/01/2019 |
| ORTWEIN, SANDRA | Individual | CORPORATE OFFICER | since 01/01/2015 |
| TULLY, FAYE | Individual | CORPORATE OFFICER | since 01/01/2004 |
| ZIBELL, JEFFREY | Individual | ADP OF THE SNF | since 10/10/2025 |
CMS files one row per role, so the 20 rows in the source record cover these 17 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.
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.
A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 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 215259. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-04-10, 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.