Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 49 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
40D
5E
3F
Potential for minimal harm
0A
0B
0C
December 19, 2025Standard inspection, Complaint inspection · 17 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to supervise a cognately impaired resident who was at high risk for elopement as evidenced by the resident leaving the facility unattended without the staff's knowledge. This deficient practice was evidenced in 1(#40) of 1 resident investigations reviewed for elopement during the recertification survey. The BIMS (Brief Interview for Mental Status) assessment is a quick standardized cognitive screening tool used in long-term care facilities to gauge a resident's orientation, attention and memory recall through simple questions about the date and repeating three words. Scored from 0-15, it helps staff track changes in cognitive function, identify potential delirium or dementia, and determine if further specialized assessment is needed. Scores are categorized: [...]
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, record review, and interviews with facility staff, it was determined that the facility failed to maintain food service equipment in a manner that ensures sanitary food service operations to prevent possible foodborne illness. This was evident during the initial tour of the kitchen.
- F
Have enough outside ventilation via a window or mechanical ventilation, or both.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and interviews with facility staff, it was determined that the facility failed to maintain clean and effective ventilation systems, thereby impeding proper airflow throughout the premises. This was evident in 13 out of 16 ventilation systems reviewed during the annual survey.
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observations and interview it was determined that the facility staff failed to ensure residents had access to their calls bells if assistance was needed. This deficient practice was evidenced in 7 (#10, #28, #44, #59, #72, #83, & #85) out of 36 residents who resided on Choptank during the recertification survey.
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to provide a clean homelike environment as evidenced by soiled and unlined waste baskets and stained wash sinks in residents' rooms. This deficient practice was observed on the Unit Choptank during the recertification survey.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide a safe, sanitary, and comfortable environment sufficient to minimize or eliminate the risk of cross-contamination as evidenced by residents who shared a bathroom personal items were not labeled and failed to implement proper hand hygiene practices to help prevent the spread of pathogenic diseases. This was evident in 13 areas within the facility that were assessed during the recertification survey.
- D
Honor the resident's right to manage his or her financial affairs.
Inspectors wroteBased on record review and interview it was determined that the facility staff failed to assure residents whose funds are being managed by the facility have ready and reasonable access to their funds. This deficient practice has the potential to affect 58 of the 93 resident whose accounts are being managed by the facility when the recertification survey was conducted.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to complete through investigations for allegations of abuse. This deficient practice was evidenced in 2 (#38 & #59) of 5 investigations reviewed for a through investigation during the recertification survey.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to notify the resident/resident representative in writing of the bed hold policy when the resident was transferred/discharged from the facility to an acute care facility. This was evident for 1 (resident # 2) of 3 residents reviewed that were transferred to an acute care facility.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and interviews it was determined that the facility staff failed to initiate a person-centered care plan for a resident who was high risk for wandering, required assistance with oral hygiene, and a resident who frequently refused ADL care. This deficient practice was evidenced in 2 (#11 & #40) of 11 resident records reviewed for person centered care plans during the recertification survey.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on medical record review and interview it was determined that the facility staff failed to adhere to professional nursing standards as evidenced by the nursing staff failure to document why a resident did not receive their enteral nutrition. This deficient practice was evidenced in 1 (#10) of 1 resident record reviewed for enteral nutrition during the recertification survey. The Maryland Nurse Practice Act guide and governs nursing practice in the state of Maryland. Registered Nurses, Licensed Practical Nurses, and certificate holders are expected to practice within the established regulations defined by the Nurse Practice Act. According to 10.27.10.02 B (3) (c) (i) The LPN contributes to the nursing assessment by recording data in a manner which is complete, timely, and accurate.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of Geriatric Nursing Assistant, (GNA) personnel files and staff interview, it was determined that the facility staff failed to conduct yearly performance reviews at least every 12 months on 1 out of 2 GNA files reviewed during the recertification survey.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on review of medical records and interview with facility staff, it was determined that the facility failed to respond to recommendations made by consulting pharmacists in a timely manner. This was evident for 1of 5 residents (Residents #4) reviewed during the investigation phase of the survey for unnecessary medications.
- D
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, record review, and interviews, it was determined that the facility failed to ensure that resident meals were palatable, sufficiently portioned, and the foods were maintained outside of the food danger zone. This was evident for 2 (Resident #82 and Resident #5) of 2 residents interviewed and 2 of 2 foodservice operation days observed during the annual survey.
- D
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on the QAPI process and interview it was determined that the facility staff were unable to report what individuals are legally responsible to establish and implement policies regarding the management and operations of the facility.
- D
Keep all essential equipment working safely.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, record review, and interviews, it was determined that the facility failed to maintain essential equipment in proper operating condition. This was evident for 4 of 4 pieces of equipment reviewed during the annual survey.
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, record review, and interviews with facility staff, it was determined that the facility failed to ensure a call bell system was accessible to residents. This was evident for 1 (Resident #8) of 1 resident's and 1of 1 restroom call bell systems reviewed during the annual survey.
March 5, 2024Standard inspection, Complaint inspection · 17 citations
- E
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to provide residents with a homelike environment. This was found to be evident for 15 residents (#11, #20, #24, #35, #39, #52, #58, #60, #61, #62, #65, #68, #70, #79, #238) out of 94 resident environments observed by the surveyors during the survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on record review, and interviews, it was determined that the facility failed to accurately document wound assessments in a resident 's medical record. This was found evident for 1 (Resident #17) of 2 Residents reviewed for pressure ulcers.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review, and interviews, it was determined that the facility failed to hold care plan meetings with an interdisciplinary team for residents at the time of the Minimum Data Set (MDS) assessment. This was found evident for 1 (Resident #17) of 5 residents reviewed for care planning.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on review of resident's medical records, and interviews, it was determined that the facility staff failed to provide activities of daily living (ADL) care in accordance with the resident's plan of care. This was found to be evident for 2 of 4 (Resident #188 and #17) residents reviewed for ADLs during an annual and complaint survey.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on interviews, record review, and facility policy, it was determined that the facility failed to provide respiratory care consistent with the professional standards for oxygen administration. This was found evident of 1 out of 3 (Resident #17) residents reviewed for respiratory care during an annual and complaint survey.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on record review, interviews and facility policy, it was determined that the facility failed to have a process in place that ensured a resident's medication irregularity report was reviewed by the primary care physician and that the recommendations were addressed timely. This was found evident of 1 (#17) of 5 residents reviewed for medication regimen review.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary drugs. This was evident for 1 (Resident #17) or 5 residents reviewed for unnecessary medications.
- D
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.
Inspectors wroteBased on interview, and medical record review, it was determined that the facility failed to limit a as needed psychotropic medication from being prescribed for less than 14 days. This was found evident in 1 (Resident #17) out of 5 residents reviewed for unnecessary medications.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to store medications appropriately according to standards of practice. This was evident for 1 of 30 medications observed during medication administration and 1 of 1 random floor observations.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observation, interviews, facility policy review, and record review, it was determined that the facility failed to maintain medical records in accordance with acceptable professional standards and practices by 1) safeguarding Resident identifiable information from the public and 2) Keeping accurate documentation. This was found evident in 3 (Resident #17, #21 and #188) of 53 Residents reviewed during the survey.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations, interviews, and review of policies and procedures, the facility failed to ensure that staff performed hand hygiene. This was evident for 2 (# 28 and # 29) out of 7 staff observed for hand hygiene.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a resident's responsible party (RP) was informed of a change in the medical regimen. This was evident for 1 (#89) out of 53 residents that were part of the survey sample.
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on clinical record review it was determined that the facility staff failed to ensure a resident's responsible party (RP) was informed of a fall. This was evident for 1 (#88) out of 53 residents in the survey sample.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interviews, and record review, it was determined that the facility failed to protect a Resident from abuse from a staff member. This was found evident of 1 of 17 (Resident #37) Residents reviewed for abuse allegations during an annual and complaint survey.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, and record review, it was determined that the facility failed to immediately report an allegation of abuse to the State Office of Health Care Quality. This was found evident in 1 out of 17 (Resident #189) Residents reviewed for abuse allegations during an annual and complaint survey.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure a thorough investigation was conducted and maintain documentation of the investigation. This was evident for 2 (Resident # 88 and #90) out of the 53 residents that were part of the survey sample.
- D
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed: 1) to ensure that a physician sent a death certificate to a funeral home and 2) failed to ensure the physician provided supervision for a resident with significant weight loss. This was evident for 1 (#337) out 3 residents reviewed for death and 1 (Resident # 96) out of 1 resident reviewed for weight loss.
March 29, 2019Standard inspection · 15 citations
- F
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and review of pertinent facility documentation it was determined that the facility failed to 1) maintain proper infection control and sanitation procedures and 2) promote a resident's dignity and respect while providing feeding assistance to a resident during lunch. This was found to be evident during observations on both units and individual observations for 1 (Resident #70) when a dining experience was observed during the facility's annual Medicare/Medicaid survey.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview and review of pertinent information it was determined that the facility failed to adequately train their Geriatric Nursing Assistants (GNA's) to serve as dietary personal during meal services.
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observations it was determined the facility failed to enhance and promote a resident's dignity and respect while providing feeding assistance to a resident during lunch. This was found to be evident for 1 resident (Resident # 70) when a dining experience was observed during the facility's annual Medicare/Medicaid survey.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on review of the facility reported incident MD00128582, investigative information, medical records and interview with staff it was determined that the facility failed to keep a resident free from abuse. This was evident for 1 out of 3 residents (Resident #81) reviewed for abuse.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to include the required statement of the resident's appeal rights and ombudsman contact information in the written notice of transfer. This was found to be evident for 2 out of 2 residents (Residents #90 and #73), reviewed for hospitalization during the investigative stage of the survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and interview with the facility staff it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the resident's status as evidenced by failure to: 1. assess medication usage and 2. assess the resident's dental condition. This was found to be evident for 2 out of 6 residents (Resident #82 and Resident #1) reviewed during the investigative stage of the survey.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on medical record review, observation and interview with facility staff, if was determined that the facility failed to follow a resident's care plan related to nutritional intervention needs. This was evident during the review of 1 of 25 residents (Resident #13) reviewed for care planning during the annual survey.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record review and interview with facility staff, it was determined that the facility failed to have an effective system in place to ensure that the hand off communication regarding resident consultations and prescriptions were clearly and effectively communicated with staff. This was evident for 1 out of 9 residents (Resident #1) reviewed during the investigative stage of the annual survey.
- D
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.
Inspectors wroteBased on review of employee files and interview it was determined that the facility failed to have an effective system in place to ensure newly hired Geriatric Nursing Assistants (GNA's) had skills assessments completed prior to being allowed to work independently with residents. This was found to be evident for 2 out of the 4 employee files (GNA #20 and #17) reviewed for new hire competencies.
- D
Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of employee files and interview it was determined that the facility failed to complete annual performance reviews for Geriatric Nursing Assistants (GNA's) for a more than a one year period of time. This was found to be evident for 2 out of the 2 GNA's (GNA #14 and #16) reviewed for annual evaluation and education.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to ensure anti-anxiety medication was destroyed after a resident expired and that narcotics that remained in the facility were included in the shift to shift narcotic count. This was found to be evident during observation of 1 of the 2 medication storage rooms.
- D
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, interview and review of medical records and facility policies it was determined that the facility failed to ensure a less than 5% error rate during medication administration as evidenced by: 1) Staff crushing medications that were on the facility Do Not Crush list, including extended release and 2) staff failing to take blood pressure prior to administering blood pressure medications. These errors were identified based on observation of 3 out of 3 residents (Residents #5, #27 and #81) observed during medication pass observation with 1 nurse on 1 unit.
- D
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation and record review and interview, the facility failed to ensure that the resident was served a therapeutic diet as prescribed by the physician. This was observed of 1 out of 14 residents (Resident #37) during the annual survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interviews with residents and facility staff it was determined the facility failed to have a resident's physician assessment as part of the resident medical record. This was found to be evident for 1 of 25 residents, (Resident # 88) reviewed during the facility's annual Medicare/Medicaid survey.
- D
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview and review of complaint and maintenance documentation it was determined that the facility failed to have an effective system in place to ensure batteries for electronic lifts were charged and available for use and failed to have documentation of preventative maintenance of the lifts. This was found to be evident on 1 of the 2 nursing units.
Fire safety inspections
33 fire safety citations on file: 9 on December 19, 2025, 19 on March 5, 2024, 5 on March 29, 2019.
Every fire safety citation33 citations
- F
Have simulated fire drills held at unexpected times.
K 712 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · December 19, 2025 · Corrected (the home has a date of correction)
- E
Have properly installed electrical wiring and gas equipment.
K 511 · December 19, 2025 · Corrected (the home has a date of correction)
- D
Install proper backup exit lighting.
K 281 · December 19, 2025 · Corrected (the home has a date of correction)
- D
Have properly located and lighted "Exit" signs.
K 293 · December 19, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · December 19, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · December 19, 2025 · Corrected (the home has a date of correction)
- F
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · March 5, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 5, 2024 · Corrected (the home has a date of correction)
- F
Meet other general requirements that are deficient.
K 500 · March 5, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 5, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 5, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 5, 2024 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · March 5, 2024 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · March 5, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · March 5, 2024 · Corrected (the home has a date of correction)
- E
Have restrictions on the use of portable space heaters.
K 781 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
K 321 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Have properly installed electrical wiring and gas equipment.
K 511 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · March 5, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · March 5, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · March 29, 2019 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · March 29, 2019 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 29, 2019 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · March 29, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 29, 2019 · Corrected (the home has a date of correction)