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Homewood Living Williamsport

16505 Virginia Avenue, Williamsport, MD 21795 · Non profit - Corporation · 82 certified beds · (301) 582-1628 Medicare & Medicaid certified

Call the home — (301) 582-1628 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse/neglect citations on record (F0600, F0602) — most recent Aug 2024Resident-funds citation (F0565)Behavioral-health or dementia-care citation — no harm found (F0758)3 actual-harm citations1 actual-harm citation CMS recorded as corrected before the inspection ended (past non-compliance)$42,266 in federal fines
Insights

This home has serious findings on its record. Read them closely before you consider it.

In its favor
  • a middle-of-the-pack inspection score (3/5)
  • a high payroll-based staffing rating (4/5)
  • lower-than-typical staff turnover (32% vs 45% nationally) — better care continuity
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has abuse, neglect, or exploitation citations (F0600, F0602) — most recent Aug 2024
  • 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 a citation for mishandling residents’ money or property (F0565)
  • it has 3 actual-harm citations
  • inspectors recorded 1 serious finding as past non-compliance — the problem was found, fixed, and verified before the survey closed, so it is history rather than a current condition, but it is still worth asking what changed
  • a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • the CMS record shows $42,266 in federal fines (most recent 2024-08-09)

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.

3/5
CMS overall
3 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 3 of 5
StaffingFrom payroll records (PBJ) 4 of 5
Quality measuresSelf-reported by the facility 4 of 5

Location & what’s nearby

Hospital
★★★ 3/5 CMS · Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
3 Byrkit Dr · (301) 582-1150 · Call to confirm hours
Pharmacy
307 E Potomac St · (301) 223-8185 · Call to confirm hours
Grocery
17603 Virginia Ave · (301) 393-3772 · Call to confirm hours
Park
11 Park Rd · (301) 223-7711 · Typically dawn to dusk
Place of worship

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

Quality measures — how residents actually fare

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

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

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 1 to 3 stars. From monthly CMS archive snapshots.

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

Overall rating3★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased7.2%20.4%15.4%better
Long-stay residents who lose too much weight5.0%5.4%5.4%typical
Long-stay residents with a catheter left in their bladder0.6%0.5%0.9%better
Long-stay residents with a urinary tract infection0.9%1.5%2.0%better
Long-stay residents with depressive symptoms1.5%22.8%6.5%better than state — see note marked double-dagger below the table
Long-stay residents who were physically restrained0.0%0.0%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury3.6%2.4%3.3%typical
Long-stay residents whose ability to walk worsened15.5%22.2%16.1%typical
Long-stay residents on antianxiety or hypnotic medication18.3%16.7%18.9%typical
Long-stay residents given the seasonal flu vaccine100.0%96.6%95.3%typical
Long-stay residents with pressure ulcers4.2%5.9%4.7%better
Long-stay residents with worsening bladder/bowel control28.3%25.0%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table28.0%13.8%17.1%worse
Short-stay residents who newly got an antipsychotic medication0.5%1.1%1.4%better
Short-stay residents given the seasonal flu vaccine95.6%80.6%79.4%better
Short-stay residents rehospitalized after admission23.8%21.0%22.6%typical
Short-stay residents with an outpatient ER visit13.4%9.8%12.0%worse
Long-stay hospitalizations per 1,000 resident days0.991.331.67better
Long-stay outpatient ER visits per 1,000 resident days1.311.201.80better

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

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

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

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

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

70.3% 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 328 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

70.3%U.S. median 51.5%
Got home and stayed home
9.5%U.S. median 10.7%
Went back to hospital
62.0%U.S. median 56.6%
Met the expected recovery
0.41U.S. median 0.31
Therapy hours / resident / day
0.22hours / resident / day
Physical therapy
0.13hours / resident / day
Occupational therapy
0.06hours / resident / day
Speech therapy

Met the expected recovery: 62.0% 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 166 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 0.41 therapist hours per resident per day in 2026Q1 — more than 70% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 23% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF70.3%CMS range 66.2–74.351.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF9.5%CMS range 7.0–12.210.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge62.0%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge59.0%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge47.0%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified98.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting97.7%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.9%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay1.0%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened5.0%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization6.0%CMS range 3.5–8.97.1%Oct 2023–Sep 2024no different from U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.841.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.83
RN hours/ resident / day
0.68
LPN hours/ resident / day
2.53
Aide hours/ resident / day
4.04
Total nurse hours/ resident / day
0.45
RN hoursweekends
31.9%
Total nursing turnover
14.3%
RN turnover

How full it usually is: this home is certified for 82 beds and averages 78.3 residents a day — about 95% occupied, or roughly 4 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.04 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.83 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.53 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.63 hrs/resident/day on weekends vs 4.21 on weekdays — 14% thinner on weekends. RN hours go from 0.98 to 0.45 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

8
deficiencies at the latest standard inspection (2026-01-09)
11
at the previous standard inspection (2024-08-09)

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

Inspection deficiencies

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

ABCDEFGHIJKL

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

30 citations, most serious first. The 14 most serious are shown; the remaining 16 are one tap away and print in full.

  • Actual harm · G2024-08-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, administrative record review, and staff interview; it was determined that the facility failed to protect a cognitively impaired resident (resident #900) from physical abuse from a facility staff member. This was evident for 1 of 5 residents reviewed during a complaint survey. After the incident, the facility implemented effective and thorough corrective measures.The facility's plan and action were verified during this survey; therefore, this deficiency will be cited as past noncompliance. The date of correction is 2/20/23 The following terms are defined for comprehension of the investigative findings: Minimum Data Set (MDS): The Minimum Data Set (MDS) is a comprehensive assessment of a resident completed by facility staff. The MDS is a multi-discipline tool that allows many facets of the resident's care [cognition, behavior, mobility, activities of daily living, accidents, activities, weight, pain, and medications to name a few] to be addressed. The MDS assessment is part of 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Past Non-Compliance
  • Actual harm · G2024-08-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, administrative record review, and staff interview; the facility failed to protect a vulnerable resident (resident #901) from a fall with major injury when facility nursing staff failed to delete an incorrect order for sleep medication (Ambien) from the resident ' s medical record. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Surveyor review of resident #901's medical record on 8/8/24 at 12:00pm revealed resident #901 was admitted to the facility for rehabilitation after orthopedic surgery. Further review of the resident ' s medical record on 8/8/24 at 12:05pm revealed the resident had a witnessed fall on 9/11/22 at 8:30am. The resident was transferred to a local hospital and was diagnosed with a fracture of the bones near the left eye. Surveyor review of the fall incident report on 8/8/24 at 12:34pm revealed resident #901 fell while being assisted by his/her assigned GNA to the bathroom. The resident was ambulating with a rolling walker when the resident lost his/her balance and fell toward his/her…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2024-08-09 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, administrative record review, policy review and staff interview; the facility failed to protect vulnerable residents (resident #901 & #174) from a significant medication error. This was evident for 2 of 30 residents reviewed during the survey. This deficient practice resulted in harm to resident # 901 who had a fall incident (accident) with major injury. The findings include: 1.) Surveyor review of resident #901's medical record on 8/8/24 at 12:00pm revealed resident #901 was admitted to the facility for rehabilitation after orthopedic surgery. Further review of the resident's medical record on 8/8/24 at 12:05pm revealed the resident had a witnessed fall on 9/11/22 at 8:30am. The resident was transferred to a local hospital and was diagnosed with a fracture of the bones near the left eye. Surveyor review of the fall incident report on 8/8/24 at 12:34pm revealed resident #901 fell while being assisted by his/her assigned GNA to the bathroom. The resident was ambulating with 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Actual harm · G2019-06-25 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on facility report review, medical record review, and staff interview, it was determined that the facility staff failed to ensure that safety interventions were followed and that the physician was provided sufficient notification regarding a recent fall with injury This is evident for 1 (#272) of 2 residents reviewed for provision of quality of care. These failures resulted in a finding of actual harm for Resident #272. The findings include: Review of the facility's investigation report MD#00139351 revealed that, on 4/12/19 at 8:30 AM, Charge Nurse and Unit Manager observed Resident #272 on the floor, blood on the head and a bruised rug burn noted on forehead. Review of the investigation revealed that the resident's floor mat was not in place at the time of the fall. Review of the progress note, written by Licensed Practical Nurse (LPN) #2 on 4/12/19 at 10:05 AM, revealed that Resident #272 was found on the floor in a pool of blood that had come from his/her nose. At 10:56 AM, LPN #2 noted a bruise to the resident's right eye during a follow up assessment. At 11:09 AM, LPN #2…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation and interview, it was determined that the facility failed to treat residents with respect and dignity, as evidenced by the failure to knock and request permission before entering a resident's room. This was evident for 1 (Resident #68) of 1 resident reviewed for dignity. The findings include:An observation on 1/6/2026 at 8:52 AM showed that Resident #68 had activated the call light for help. Staff #7, a geriatric nurse aid, entered Resident #68's room in response to the call light. However, the observation did not show that Staff #7 knocked on the resident's door or requested permission before entering the room.During an interview at that time, Staff #7 was asked whether she knocked on Resident #68's door before entering the Resident's room. Staff #7 confirmed that she did not and added that she simply wanted to answer the light.A record review later that day indicated that Resident #68 was alert, oriented, able to communicate his/her needs, and able to understand others.In an interview on 1/8/2026 at 1:57 PM, the director of nursing (DON) was informed of…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0558 — failed to accommodate residents' needs and preferences — isolated
    Reasonably accommodate the needs and preferences of each resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations, and interviews, it was determined that the facility failed to ensure that call devices were kept within residents' reach. This was evident in 1 (Resident #9) of 24 residents reviewed in the initial pool of the survey.The findings include:A call device is a communication tool that allows residents to alert staff when they need help.The Minimum Data Set (MDS) is a federally mandated assessment tool used by nursing home staff to gather information on each Resident's strengths and needs. Information collected drives resident care planning decisions.A record review for Resident #9 included an MDS assessment dated [DATE]. The MDS noted that Resident #9 had moderate cognitive impairment and was dependent on staff for most self-care needs. An observation on 1/5/2026 at 9:43 AM showed Resident #9 lying in bed with a call device clipped to the side of the bed. The Resident was asked about the call device; s/he attempted to reach for it but was unable to. The Resident added that…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0565 — failed to support the resident council — isolated
    Honor the resident's right to organize and participate in resident/family groups in the facility.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, observation, and interview, it was determined that the facility failed to ensure residents' grievances were identified, investigated, documented, and responded to. This was evident during the annual recertification survey when reviewing the facility resident council. The findings include: 1/08/2026 9:29 AM after an interview with R#3, permission was given to the surveyor to review the resident council meeting minutes, and Staff #12 provided the resident council meeting minutes for January - December 2025 for review. 1/08/2026 11:50 AM The surveyor asked Staff #13, identified as the facility's grievance officer, for copies of the grievance logs for the previous 12 months to correlate with the resident council meeting minutes that had been reviewed. Staff #13 provided the surveyor with the grievance log and the facility policy stating, We have not had any grievances for all of 2025. A binder was provided to the surveyor that contained 2024, 2025, and 2026 grievance logs. 1 entry existed for 12/14/2025 stating that unit manager submitted a grievance, with 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0585 — failed to handle grievances — isolated
    Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of Resident Council meeting minutes, grievance logs, facility policy, and staff interviews, the facility interfered with residents' right to file grievances by failing to maintain and implement a functional grievance process. This was evident during the annual recertification survey. The findings include: Cross-referencing related findings from F565:Resident complaints documented in Resident Council meetings were screened by the activities staff and handled informally without being recognized or processed as grievances. The absence of a functional grievance system prevented residents' concerns from being formally filed, investigated, documented, or responded to. On 1/08/2026 at 11:59 AM, review of Resident Council meeting minutes from January-December 2025 identified resident complaints regarding call bell response times, food temperature and preferences, frequency of bed linen changes, and staff entering resident rooms without identifying themselves.On 1/08/2026 at 11:50 AM, review of the facility's grievance logs revealed no grievances for 2025, except for one…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0679 — failed to provide activities — isolated
    Provide activities to meet all resident's needs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interviews, it was determined that the facility failed to provide activities to residents based on their comprehensive assessment to support the physical, mental, and psychosocial well-being. This was evident for 1 (Resident #3) of 3 residents reviewed for activities.The findings include:Resident #3 had been a resident of the facility since early 2022. The resident was interviewed on 1/5/26 at 9:34 AM. During the interview, the resident stated, we are trapped like prisoners, we never get to go out.A review of Resident #3's most recent annual comprehensive assessment with a reference date of 9/3/25 was conducted on 1/6/26 at 12:25 PM. The review indicated that the resident had a normal cognitive status, and that it was very important for the resident to go outside to get fresh air when the weather is good. The resident's care plan for activities was also reviewed and revealed interventions that include please invite and encourage me to go outside when the weather permits dated 8/16/22. In Resident #3's electronic health record, the daily charting 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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolated
    Provide safe and appropriate respiratory care for a resident when needed.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observations, record reviews, and interviews, it was determined that the facility failed to follow an attending physician's order to administer oxygen to a resident. This was evident in 1 (Resident #94) of 1 resident reviewed for Respiratory Care during the survey. The findings include:On 1/5/2026 at 1:55 PM, Resident #94 was observed lying in bed and receiving oxygen via a nasal cannula connected to an oxygen concentrator set to 4 L/min (liters per minute).During a subsequent observation on 1/6/2026 at 9:01 AM, Resident #94 was in bed and continued to receive oxygen via nasal cannula at 4 L/min.A review of Resident #94's medical record contained an attending provider's order initiated on 12/23/25 for oxygen at 2L/min every shift for hypoxia.During an interview on 1/6/2026 at 10:07 AM, staff #10, the head nurse for the second-floor unit, was present in Resident #94's room with the surveyor. Staff was asked to confirm Resident #94's oxygen flow rate at that time; she reported it was set to 4 L/min. Staff #10 then stated that Resident #94 should receive 2 L of oxygen and…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-01-09 · tag F0697 — failed to manage pain — isolated
    Provide safe, appropriate pain management for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record reviews and interviews, it was determined that the facility failed to ensure pain management was provided to the resident based on professional standards of practice. This was evident for 1 (Resident #3) of 5 residents reviewed for unnecessary medications. The findings include: Resident #3 was admitted into the facility in 2022 with diagnosis that includes but is not limited to lumbar radiculopathy, left shoulder pain, and rupture/tear of the left shoulder rotator-cuff. A review of Resident #3's electronic medication administration record (eMAR) for December 2025 was conducted on 1/7/26 at 1:56 PM. The review revealed an order for a narcotic pain medication scheduled to be taken as needed for pain. This medication was administered 14 times. The notes section of the eMAR revealed documentation from the nurses that indicated the resident's pain score, before med administration and the follow up pain score. However, the 12/7/25 at 10 AM administration did not indicate the before and follow-up pain score, the 12/12/25 at 4:56 PM administration had no follow-up pain…

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

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-01-09 · tag F0880 — failed to prevent and control infections — isolated
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, observations, and record reviews, it was determined that the facility failed to develop and implement infection prevention and control policies and procedures, as evidenced by staff not wearing appropriate personal protective equipment (PPE) before providing direct care to residents. This was evident in 2 (Resident #13 and #12) of 4 residents reviewed for pressure ulcers.The findings include:Enhanced Barrier Precautions (EBP) are infection-control interventions designed to reduce the transmission of infection in nursing homes. They involve wearing gowns and gloves during high-contact Resident care activities, such as dressing, bathing or showering, transferring, changing linens, providing hygiene, changing briefs, or assisting with toileting for residents with a central line, urinary catheter, feeding tube, tracheostomy, or any skin opening requiring dressing. 1.) An interview with Resident #13's representative on 1/5/26 revealed that the Resident had a facility-acquired wound to the sacrum (tailbone) area. A review of Resident #13's medical record 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-09 · tag F0835 — failed to run the facility competently — widespread
    Administer 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, staff interview, and policy review, the facility's administration failed to implement its Resident Immunization policy related to current Centers for Disease Control (CDC) recommendations to provide residents the opportunity to receive the Prevnar (Pneumococcal conjugate vaccine (PCV) 20) or the PCV15. Eight out of eight residents ((R) 14, R21, R10, R32, R35, R2, R19, and R36) reviewed for immunizations were not offered pneumococcal vaccinations in compliance with CDC recommendations, the facility had never had PCV20 available, and the facility failed to identify the potential for deficient practice in quality assurance. These failures had the potential to increase the risk of residents contracting pneumonia. Findings include: Review of a facility policy titled Resident Immunization dated 11/08/23 indicated . The facility will offer residents immunization against vaccine-preventable diseases that may be encountered in the facility and as recommended by the CDC Advisory Committee for Immunization Practices . Upon admission or shortly thereafter, each…

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

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-09 · tag F0867 — failed to act on quality-improvement findings — widespread
    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interviews, review of the facility documentation, and policy review, the Quality Assessment (QA) committee failed to identify quality deficiencies related to the facility's infection control program and take corrective action to ensure that Prevnar (PCV) 20 was offered and provided in accordance with recognized national standards. This failure had the potential to affect all residents who were eligible for the PVC20 vaccine who currently live in the facility. Findings include: Review of a facility document titled Quality Assurance, dated 03/25/22, indicated the Consultant Pharmacist provided the QA committee members with the Centers for Disease Control and Prevention (CDC) recommendations of Prevnar20. During an interview on 08/07/24 at 10:17 AM, the Consultant Pharmacist confirmed she participated in the quarterly QA meetings. The Consultant Pharmacist stated during one QA meeting in 2022 she provided the QA members information on the Prevnar20 vaccination and the CDC recommendations. The Consultant Pharmacist was asked why the facility never implemented the CDC…

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

    Administration Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · Fcited before2024-08-09 · tag F0880 — failed to prevent and control infections — widespread
    Provide and implement an infection prevention and control program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on observation, interview, and review of facility policies, the facility failed to ensure protective equipment (PPE) was available for laundry staff in one of one laundry rooms while sorting soiled resident clothing and bed linens. This had the potential to infect the staff and/or residents with pathogens which could potentially lead to the development of infectious diseases. Findings include: During a tour of the soiled laundry room on 08/09/24 at 8:41 AM, gloves were observed but no gowns. An immediate interview was conducted with Housekeeper 1, and she confirmed when she handled the soiled linens from the floors, she did not don (put on) a gown and only used gloves. The Director of Housekeeping/Laundry (DHL) was present during this interview and confirmed the same information. The DHL stated the laundry staff would retrieve the bagged soiled laundry from a bin and then place the bag open end first into the washing machine. The DHL stated there was no contact between the soiled laundry and the laundry staff. During an interview on 08/09/24 at 8:44 AM, 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.

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-09 · tag F0883 — failed to offer flu and pneumonia vaccines — widespread
    Develop and implement policies and procedures for flu and pneumonia vaccinations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review, the facility failed to offer eight of eight residents (Resident (R) R14, R21, R10, R32, R35, R2, R19, and R36) reviewed for immunizations and/or their representatives the opportunity for the resident to be vaccinated in accordance with nationally recognized standards out of a current facility census of 69. This practice had the potential to increase the risk for the residents to contract pneumonia. (Cross Reference F835 and F867) Findings include: Review of a facility policy titled Resident Immunization dated 11/08/23 indicated . The facility will offer residents immunization against vaccine-preventable diseases that may be encountered in the facility and as recommended by the CDC Advisory Committee for Immunization Practices . Upon admission or shortly thereafter, each resident's status for influenza, pneumococcal . will be determined and recorded in the medical record .…

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

    Infection Control Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-08-09 · tag F0944 — widespread
    Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, interview, and policy review, the facility failed to ensure five staff (Geriatric Nursing Assistant (GNA) 4, GNA5, and GNA6); (Licensed Practical Nurse (LPN) 9) and (Registered Nurse (RN) 3) of five random nursing staff reviewed for staffing were trained in the facility's Quality Assurance Performance Improvement (QAPI) Program. Findings include: Review of a facility policy titled Staff Development Program, dated May 2019, indicated All personnel must participate in initial orientation and regularly scheduled in-service training classes . The primary objective of our facility's staff development program is to ensure that staff have the knowledge, skills and critical thinking necessary to provide excellent resident care . Required training topics include the following: Elements and goals of the facility QAPI program . Review of documents provided by the facility titled Relias [an on-line training program] revealed the following: 1. CNA4's date of hire was 11/02/23 and her training failed to address the facility's QAPI program. 2. CNA5's date of hire 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.

    Administration Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0640 — isolated
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    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, record review, and Resident Assessment Instrument (RAI) Manual review, the facility failed to follow the RAI's transmission requirements, which indicate that within 14 days after a facility completes a resident's assessment a facility must electronically transmit encoded, accurate, and complete ''Minimum Data Set (MDS) data to the Center for Medicare & Medicaid Services (CMS) System, for one (Resident (R) 25) of one supplemental residents reviewed for Resident Assessment. Specifically, it had been over 120 days since the discharge ''MDS'' was completed and the ''MDS'' had not been transmitted to the CMS System. Findings include: Review of R25's undated ''Face Sheet'' located in the electronic medical record (EMR) under the ''Dashboard'' tab, revealed R25 was admitted to the facility on [DATE] with the diagnoses of congestive heart failure (CHF) and pneumonia. Review of R25's admission ''Minimum Data Set (MDS)'' located in the EMR under the ''MDS'' tab with an ''Assessment Reference Date…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0726 — failed to have competent, trained nursing staff — isolated
    Ensure 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

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and policy review, the facility failed to provide education for two staff members to possess the competencies and skill sets necessary to ensure residents were free of medication errors for two of four residents (Resident (R) 174 and R15) reviewed for medications in a total sample of 26 residents. These failures resulted in the residents receiving the wrong dose of medications. Findings include: 1. Review of R174's undated Face Sheet, located in the electronic medical record (EMR) under the Dashboard tab, revealed R174 was admitted to the facility on [DATE] with multiple diagnosis including other disorder of bone, cervical disc degeneration and arthritis. Review of R174's Physician's Orders, dated 04/16/22 and located under the Physician Orders tab of the EMR, revealed an order for oxycodone hydrochloride (HCL) immediate release (IR) 5 milligrams (MG) tablet take 1/2 tablet (2.5 MG) by mouth every 8 hours and every 6 hours as needed (PRN) for severe pain. Review of R173's…

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

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0755 — failed to provide safe pharmacy services — isolated
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, administrative record review, and staff interview; the facility failed to maintain an accurate resident (resident #901) medication order history. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Surveyor review of a self-report (MD00190723) on 8/8/24 at 12:45pm, dated 9/15/22, revealed the facility completed an investigation of the resident's fall and discovered the root cause of the resident's fall was over-administration of the resident's prescribed sleep medication (Ambien) on 9/10/22. The facility further discovered in the investigation that the facility nursing staff over-administered the resident's sleep medication was following provider orders transcribed by facility nursing staff on 9/8/22 at 5:38pm. Surveyor review of a medication error report on 8/8/24 at 1:15pm revealed the document, dated 9/11/22, reported that RN # 307 transcribed a provider order for a one-time dose of Ambien for 12.5mg on 9/8/22 at 5:38pm. RN #307 administered the one-time dose of Ambien and failed to discontinue 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview with staff it was determined the facility staff failed to ensure each residents drug regimen was free from unnecessary drugs. This was evident for 1 (#21) of 3 residents reviewed for unnecessary psychotropic drugs. The findings include: Resident #21's record was reviewed on 10/15/24 at 1:45 PM. A consultant pharmacist monthly review was completed on 10/1/24. The review indicated that a recommendation was given. The note to the attending physician identified that Resident #21 had an order for metformin 500 mg(milligrams)( an oral medication used to treat diabetes) twice a day and that his/her A1c (a lab test which reflects blood glucose control over time), was well within the goal. Please consider reducing his/her metformin to 500 mg daily. The physicians response at the bottom of the note, signed and dated 10/4/24, indicated: Agree and Okay to change metformin to 500mg daily. Review of the October Medication Administration Record (MAR) revealed Resident #21 received Metformin 500 mg at 8:00 AM and 5:00 PM each day in October up to and including…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, administrative record review, and staff interview; the facility failed to ensure a resident's medication regimen was free from unnecessary PRN (as needed) medications (resident #901). This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Surveyor review of a self-report (MD00190723) dated 9/15/23 revealed the facility completed an investigation of the resident's fall and discovered the root cause of the resident's fall was over-administration of the resident's prescribed sleep medication (Ambien) on 9/10/22. The facility further discovered in the investigation that the facility nursing staff over-administered the resident's sleep medication was following provider orders transcribed by facility nursing staff on 9/8/22 at 5:38pm. Surveyor review of a medication error report on 8/8/24 at 1:15pm revealed the document, dated 9/11/22, reported that RN # 307 transcribed a provider order for a one-time dose of Ambien for 12.5mg on 9/8/22 at 5:38pm. RN #307 administered the one-time dose of Ambien and failed 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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-08-09 · tag F0759 — failed to keep medication error rate low — isolated
    Ensure medication error rates are not 5 percent or greater.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of facility policy, the facility failed to ensure a medication error rate below five percent. During medication administration two medication errors for two residents (Residents (R) 15 and R65) were made of 39 opportunities resulting in a medication error rate of 5.13 percent. These failures had the potential to increase or decrease the effectiveness of these medications. Findings include: 1. Review of R15's undated Face Sheet located in the electronic medical record (EMR) under the Dashboard tab, revealed R15 was admitted to the facility on [DATE] with the diagnoses including type 2 diabetes mellitus (DM). Review of R15's Physician Orders located in the EMR under the Physician Orders tab, revealed an order dated 08/03/24 for Lantus Solostar U-100 insulin 100 unit/milliliters (ML) (3 ML) subcutaneous pen [insulin glargine, a long acting insulin] - 5 [five] units subcutaneous every day for DM. During an observation on 08/09/24 at 8:53 AM, Licensed…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-08-09 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, administrative record review, and staff interview; the facility failed to maintain an accurate resident (resident #901) medication order history. This was evident for 1 of 4 residents reviewed during a complaint survey. The findings include: Surveyor review of a self-report (MD00190723) on 8/8/24 at 12:45pm, dated 9/15/22, revealed the facility completed an investigation of the resident's fall and discovered the root cause of the resident's fall was over-administration of the resident's prescribed sleep medication (Ambien) on 9/10/22. The facility further discovered in the investigation that the facility nursing staff over-administered the resident's sleep medication was following provider orders transcribed by facility nursing staff on 9/8/22 at 5:38pm. Surveyor review of a medication error report on 8/8/24 at 1:15pm revealed the document, dated 9/11/22, reported that RN # 307 transcribed a provider order for a one-time dose of Ambien for 12.5mg on 9/8/22 at 5:38pm. RN #307 administered the one-time dose of Ambien and failed to discontinue the…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-25 · tag F0602 — failed to protect residents from theft of their belongings — isolated
    Protect each resident from the wrongful use of the resident's belongings or money.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on medical record review, facility report review, and staff interview, it was determined that the facility failed to ensure the resident's right to be free of misappropriation of property. This was evident for 1 (#271) of 2 residents reviewed for abuse. The findings include: A review of a facility's investigation report was conducted on 6/20/19 at 10:00 AM. The report revealed that, on 02/25/18, Licensed Practical Nurse LPN #20 emailed the Unit Manager (UM) staff #21 that she discovered 13 muscle relaxant pills from a blister pack that belonged to Resident #271 were missing and not accounted for on the resident's Medication Administration Record (MAR). On 2/2718, LPN #20 returned to work. She discovered that the same blister pack had 8 additional pills missing, but were not accounted for in the resident's MAR and reported the incidents to the Director of Nursing (DON). Further review of the report indicated that the facility determined there were 22 missing and unrecorded muscle relaxer pills. The facility interviewed 11 staff members that had access to Resident# 271's…

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

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-25 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review, facility report review, and staff interview, it was determined that the facility staff failed to recognize and report an alleged misappropriation of property to Administration immediately. This was evident for 1(#271) of 2 investigated for abuse. The findings include: A review of the facilities investigation report on 6/20/19 at 10:00 AM, revealed that LPN #20 conducted a medication cart check on Sunday, 2/25/18 and found that Resident #217's blister pack of muscle relaxers had 13 pills missing. She checked the Medication Administration Record (MAR) and discovered that the pills had not been signed as being given to the resident. Although LPN #20 reported to Unit Manager (UM) #21 on 2/25/18, via an email, the LPN failed to report the incident to the weekend Supervisor present in the facility that day. When LPN #20 returned to work on 2/27/18 and discovered 8 additional pills missing from the same blister pack that were also not accounted for in the resident's MAR, she reported the incidents to the Director of Nursing. During an interview with 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-25 · tag F0610 — failed to investigate and act on abuse reports — isolated
    Respond appropriately to all alleged violations.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and staff interview, it was determined that the facility failed to put a plan in place to ensure facility staff identify incidents of misappropriation of residents' property and report allegations immediately with administration. This was evident for 1 (#271) of 2 residents reviewed for abuse. The findings include: Review of the facility's investigation report on 6/20/19 at 10:00 AM, revealed Charge Nurse LPN #20 discovered 13 missing muscle relaxer medication for Resident #271. Further review revealed that she did not identify the event as an abuse and did not report it immediately to the Nurse Supervisor present in facility. During an interview with the Director of Nursing (DON) and Administrator on 6/20/19 at 12:49 PM, the DON stated that she did not expect the staff to recognize this as misappropriation of property. She added that the staff would consider the incident as a documentation issue. She admitted that although abuse was indicated two days after 8 additional pills were taken, she did not initiate corrective action for her staff regards 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2019-06-25 · tag F0624 — isolated
    Prepare residents for a safe transfer or discharge from the nursing home.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the resident's record and interview with staff, it was determined the facility staff failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer. This was evident for 2 (#47, #40) of 5 residents reviewed for Hospitalization. The findings include: 1) A brief review of resident #47's medical record on 6/19/19 at 1:56 PM revealed he/she was transferred to the hospital on 6/7/19 for evaluation after experiencing changes in his/her condition. Further review of the record on 6/25/19 at 8:42 AM revealed nursing progress notes documenting initial observations and ongoing assessments of the residents changing condition. The notes included notification of the physician and the residents responsible party, that report was called to the Meritus Medical Center Emergency room, that the resident's transportation was provided via Emergency Medical Systems and described the paperwork that was sent with the resident. The record failed to reveal that the facility informed the resident in a form and manner that he/she could…

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

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2019-06-25 · tag F0842 — failed to keep accurate, complete medical records — isolated
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the medical record and interview with staff, it was determined the facility failed to ensure that the residents' medical record contained complete and accurately documented information. This was evident for 1 (#26) of 4 residents reviewed for Abuse. The findings include: Resident #26's medial record was reviewed on 6/21/19 at 11:32 AM. The record revealed that, on 7/19/18, Resident #26 reported that a Hospice GNA (Geriatric Nursing Assistant) had forced her agenda on him/her by trying to provide care he/she did not want, and that his/her private area was hurt when she ripped his/her brief off. The facility investigated the allegation and was unable to substantiate that the resident had been mistreated. The facility initiated resident care interventions which included, but were not limited to, Hospice GNA's no longer providing care for Resident #26, monitoring the resident's behaviors and refusals of care, and for 2 facility staff to provide personal hygiene, toileting, bathing and incontinence care due to the resident accusing staff at times. The record contained…

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

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • No harm found · C2019-06-25 · tag F0756 — failed to review each resident's drug regimen — widespread
    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on review of the medical record and interview with facility staff, it was determined that the facility staff failed to ensure irregularities reported to the attending physician by the pharmacist were acted upon for 1 (#41) of 5 residents reviewed for Unnecessary Medication review. The findings include: Resident #41's medical record was reviewed on 6/25/19 at 10:15 AM. The monthly drug regimen review note indicated that the pharmacist made a referral to the physician on 6/4/19, however, the actual referral was not in the record. During an interview on 6/25/19 at 11 AM, The unit manager (staff #1) and Unit Clerk (staff #6) were unable to find the referral as they had first looked in the resident's paper chart. At 11:20, AM staff #1 reported that the pharmacy recommendation was found. Staff #1 acknowledged that it was her responsibility to have resident #41's attending physician respond to the pharmacist recommendations. The pharmacist referral/recommendation form indicated that resident #41 was consistently having high finger-stick readings (for diabetic blood glucose…

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

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

$42,266 in federal fines across 1 penalty.

  • $42,266 — penalty dated 2024-08-09

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

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

RatingThis homeChain avg
Overall 3 of 54.3-1.3 vs chain
Health inspection 3 of 54.0-1.0 vs chain
Staffing 4 of 54.5-0.5 vs chain
Quality measures 4 of 54.3-0.3 vs chain
The other 3 homes this chain runs (chain average 4.3★, per CMS)

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

Who owns this facility

Owner / managerTypeRoleSince
BRUMBELOW, DAVIDIndividualCORPORATE DIRECTORsince 01/01/2024
CRAMPTON, WENDYIndividualCORPORATE DIRECTORsince 03/01/2019
DITTO, ALLENIndividualCORPORATE DIRECTOR; ADP OF THE SNFsince 01/01/2011
HOWSER, KARENIndividualCORPORATE DIRECTORsince 12/01/2024
LINE, MICHAELIndividualCORPORATE DIRECTORsince 01/01/2019
MILLER, RICHARDIndividualCORPORATE DIRECTORsince 01/15/2021
ROTHROCK, THADIndividualCORPORATE DIRECTORsince 03/01/2019
SCOTT, RANDYIndividualCORPORATE DIRECTORsince 01/01/2022
ZORETICH, STEVEIndividualCORPORATE DIRECTORsince 12/01/2024
MITCHELL, RUSSELLIndividualOPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNFsince 01/29/2026

CMS files one row per role, so the 12 rows in the source record cover these 10 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.

$15.4M
Net patient revenuemost recent cost report
-39.4%
Operating marginrevenue minus expenses
$1.2M
Related-party expense6% of expenses
Who pays — share of resident-days
Medicaid 21%Medicare 11%Other / private 68%

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent 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

$490per resident / day
operating cost
$14,886per month
≈ monthly operating cost
$351per day
avg. revenue, all payers

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

What families pay in MD

Paying with Medicaid

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

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

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

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 215225. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-01-09, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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