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Home / Maryland / Denton

Caroline Nursing and Rehab

520 Kerr Avenue, Denton, MD 21629 · Caroline County · (410) 479-2130

87 certified beds, about 85 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1971

Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
2 of 5
Quality measures
2 of 5

CMS Care Compare ratings, data as of September 1, 2026 · CCN 215083 · See it on Medicare.gov · Compare with other homes

The record in brief

At its most recent standard inspection, on November 22, 2024, inspectors cited 13 health deficiencies (the Maryland average is 17, the national average 9.2).

None of its 42 health citations since May 2018 was rated as actual harm or immediate jeopardy.

CMS lists no fines against this home in the last three years.

Nurses and nurse aides worked 3.33 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.58 of those hours.

44.4% of nursing staff left within the year CMS measured (Maryland average 40.2%).

CMS links it to Key Health Management, an affiliated group of 7 nursing homes.

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 42 health citations on file.

Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
32D
6E
4F
Potential for minimal harm
0A
0B
0C
March 13, 2026Complaint inspection · 1 citation
  1. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) April 15, 2026
    Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide activities of daily living (ADL) care by ensuring timely assistance with toileting. This is evident for 1 (Resident #96) of 7 residents reviewed for ADL care.
October 29, 2025Complaint inspection · 4 citations
  1. E
    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
    F755 · Pharmacy Service · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) December 2, 2025
    Inspectors wroteBased on the investigation of complaints, reviews of medical records, and interviews with staff, it was determined that the facility failed to 1) appropriately manage narcotic medications, and 2) give medications as ordered by a Physician. This was evident for 4 (Resident #4, #8, #9, and #12) of 14 residents reviewed during the complaint survey.
  2. D
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    F628 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 2, 2025
    Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to ensure the discharge of a resident was documented in the medical record that included the resident's status at the time of discharge and the reason for the discharge. This was identified for 1 (Resident #12) of 3 residents reviewed for discharge during the complaint survey.
  3. D
    Ensure that residents are free from significant medication errors.
    F760 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 2, 2025
    Inspectors wroteBased on review of Intakes, medical record review, and staff interview it was determined that the facility failed to 1) properly monitor a resident's status after a significant medication error, 2) Notify the physician before withholding a medication used to regulate blood sugar, and 3) ensure that a resident's medications were administered as ordered. This was evident for 2 (Resident #13 and #4) of 2 residents reviewed for medication administration during this complaint survey.
  4. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) December 2, 2025
    Inspectors wroteBased on the investigation of complaints, record review, and staff interviews, it was determined that the facility staff failed to document the administration of medication in a resident's Medication Administration Record (MAR). This was evident for one (Resident #4) of the four residents reviewed for medication administration during the complaint survey.
June 27, 2025Complaint inspection · 1 citation
  1. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) July 29, 2025
    Inspectors wroteBased on closed medical record review and interview, the facility failed to ensure a resident's drug regimen was free from an unnecessary drug (Resident #1). This was evident for 1 of 4 residents reviewed during a complaint survey.
November 22, 2024Standard inspection, Complaint inspection · 18 citations
  1. F
    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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that all nursing staff had competency evaluations. This was evident for six (Licensed Practical Nurses #19, #40, #41, Geriatric Nursing Aides #42, #43, and #44) of the six randomly selected nursing staff reviewed for competencies.
  2. F
    Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
    F800 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on complaint #MD00206921, complaint #MD00199493, resident interviews and staff interviews, it was determined that 1) the facility failed to provide sufficient food of adequate quality to meet residents' dietary needs and preferences which has the potential to affect all residents in the facility, and 2) the facility failed to ensure diabetic residents received snacks to meet their dietary needs which was evident in 1 (anonymous resident) of 3 Residents reviewed for meal accuracy during the recertification survey. The Findings Include: 1)On 11/12/2024 11:49 AM, in an interview with Resident#19, the resident stated that when he/she does not like the food served at the facility, he/she orders a salad or grilled cheese sandwich, but it was not always available. [...]
  3. F
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    F812 · Nutrition and Dietary · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on the kitchen tour and staff, it was determined that the facility failed to ensure that stored food items were labeled and were not expired. This deficient practice has the potential to affect all residents in the facility. The Findings Include: During the initial kitchen tour on 11/12/24 with the Food Service Director (FSD, Staff #12), the following deficient practices were revealed: On 11/12/24 at 9:23 AM, observation of the walk-in refrigerator revealed: a large open container of salsa was dated 8/12/2024 but also had a handwritten facility label of 9/28/2024; a large open container of sour cream best-by date of 10/22/2024; a 5lb bag of cubed potatoes unlabeled; a 2lbs of open pasteurized liquid eggs undated; and a bag of mixed salad open and undated. On 11/12/2024 at 9:30 AM, observation of the walk-in freezer revealed the following items that lacked labels and were not dated: [...]
  4. F
    Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
    F947 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, widespread · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that all Geriatric Nursing staff had competency evaluations. This was evident for three (Geriatric Nursing Aides #42, #43, and #44) of the three randomly selected nursing staff reviewed for competencies.
  5. E
    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
    F657 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on complaints, observation, record review, and interview, it was determined the facility staff: 1) failed to revise and update resident care plans to reflect accurate and current interventions, and 2) failed to have timely care plan meetings with a resident and/or resident representative. This was evident for 6 (#38, #68, #63, #19, #37, #241) of 38 residents reviewed during a recertification/complaint survey.
  6. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on an interview with a resident, a record review and interview with facility staff, it was determined that the facility failed to ensure comprehensive care plans were developed and implemented. This was evident for 3 residents (Resident #11, Resident # 57 and Resident # 247) out of 38 residents reviewed for developing the comprehensive care plans during the Medicaid/Medicare recertification survey.
  7. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on record review and interview with the facility staff and residents, it was determined that the facility staff failed to provide an activities program to meet the needs and preferences of residents. This was evident for 1 (Resident #11) of 6 residents reviewed for activities during the Medicare/Medicaid Recertification survey.
  8. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on the medical record review, resident interview, and staff interview, it was determined that the facility failed to 1) ensure that a resident (Resident #244) received appropriate care regarding dysphagia by failing to supervise and/or assist with feeding, and additionally develop a care plan for dysphagia and 2) ensure adherence to the prescribed frequency and medication administration time (Resident #37, #14). This was evident for 3 (Resident #244, #37, #14) of 38 residents reviewed during the recertification/complaint survey.
  9. D
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    F686 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on a complaint, observation, resident and facility staff interviews, and medical record review, the facility failed to prevent new pressure ulcers and document weekly skin and wound assessments for residents with pressure ulcers. This was evident for 1 (Resident # 246) out of 2 residents who were reviewed for pressure ulcer prevention and treatment during the recertification/complaint survey.
  10. D
    Provide safe and appropriate respiratory care for a resident when needed.
    F695 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on observation, medical record review, and interview, it was determined the facility staff failed to date and label oxygen administration equipment and maintain a nasal cannula in a sanitary manner to prevent potential infection . This was evident for 2 (#39, #74) of 3 residents reviewed for respiratory care during a recertification/complaint survey.
  11. D
    Observe each nurse aide's job performance and give regular training.
    F730 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on a review of employee records and interviews, it was determined that the facility staff failed to conduct performance reviews of Geriatric Nursing Assistants (GNAs) and Licensed Practical Nurses (LPN) at least once every 12 months. This was evident for 3 (GNA #42, #43, #44) and 2 Licensed Practical Nurses (#19, #41) of 6 randomly selected nursing staff records reviewed for annual training requirements during the recertification/complaint survey.
  12. 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.
    F761 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on observation and interview it was determined facility staff failed to remove expired medications and patient supplies. This was evident on 2 of 4 nursing units and a central supply room observed during a recertification/complaint survey.
  13. D
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on observation, review of resident medical records, review of facility policy, and interview with facility staff, it was determined that the facility failed to ensure that 1) physician's order for appropriate infection control signage with a COVID-19 positive resident was implemented, 2) follow-up tests were conducted for residents exposed to COVID-19, and 3) failed to ensure that a resident known to be positive for Covid-19 was isolated upon readmission as the resident was readmitted directly into original room with roommate. This was evident for 1 resident(Resident #55) out of 2 residents reviewed for Isolation precautions during the recertification/complaint survey.
  14. E
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, pattern · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on the record reviews and interviews, and observations, it was determined that the facility failed to thoroughly investigate an abuse allegation. This is evident for 5 (Resident#232, #235, #63, #32, #7) of 38 residents reviewed during the recertification/complaint survey.
  15. D
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    F580 · Resident Rights · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on a complaint, review of medical records, and staff interview, it was determined facility staff failed to notify a resident's representative when a resident had a medication change. This was evident for 1 (Resident #7) of 15 residents reviewed for complaints during a Recertification/Complaint survey.
  16. D
    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
    F600 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on a review of the facility self-report, record reviews, resident interview, and staff interviews, it was determined that the facility failed to ensure residents were free from verbal abuse. This is evident for 1(Resident #63) of 10 residents reviewed for abuse during the recertification/complaint survey.
  17. D
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    F609 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to timely report verbal abuse to the State Survey Agency and other agencies as required by law. This is evident for 1 (Resident #63) of 9 residents reviewed for facility reported incidents during the recertification/complaint survey. Findings Include: On 11/15/2024 at 10:50 AM, a review of a Facility Reported Incident submitted to the Office of Health Care Quality (OHCQ) revealed that a self-report for verbal abuse against Resident #63 was submitted to OHCQ on 8/22/2024 at 4:09 PM; however, this alleged incident was witnessed by another resident's family member who notified the supervisor of the incident on 8/21/2024 at 6:35 PM. On 8/21/24, it was alleged that Resident #63 was verbally abused by a Geriatric Nurse Aide (GNA). [...]
  18. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · found on a complaint visit · Corrected (the home has a date of correction) January 17, 2025
    Inspectors wroteBased on a review of the resident medical records and an interview with facility staff, it was determined that the facility failed to address a significant weight loss for the resident. This was evident for 1 (Resident #238) of 7 residents reviewed for nutrition during this survey.
October 11, 2019Standard inspection · 11 citations
  1. E
    Reasonably accommodate the needs and preferences of each resident.
    F558 · Resident Rights · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on observation, record review, and interview, it was determined that the facility staff failed to ensure access to the nurse call bell for residents who were totally dependent on nursing staff due to impaired mobility. This was evident for 4 (#73, #28, #22, #64) of 20 residents reviewed during the initial pool process.
  2. E
    Provide and implement an infection prevention and control program.
    F880 · Infection Control · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to develop and implement infection control policies and procedures to prevent resident exposure to tuberculosis and childhood communicable diseases. This was evident for 5 (#13, #14, #15, #16, and #17) of 5 employee files reviewed for immunity of communicable diseases and screening for tuberculosis.
  3. D
    Respond appropriately to all alleged violations.
    F610 · Freedom from Abuse, Neglect, and Exploitation · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on record review, resident interview, and staff interview, it was determined that the facility failed to keep an alleged abuser away from the resident during the investigation. This was evident for 1 (Resident #31) of 3 residents reviewed for abuse.
  4. D
    Ensure each resident receives an accurate assessment.
    F641 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the residents status as evidenced by the failure to assess the presence of cracked teeth and failed to assess the use of a wanderguard device. This was found to be evident for one of one resident (Resident #55) reviewed for dental and one of six residents (Resident #4) reviewed for accidents. 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. MDS assessments need to be accurate to ensure that each resident receives the care they need.
  5. D
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    F655 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure the baseline care plan included instructions needed to provide effective and person-centered care of the resident that meets professional standards as evidenced by failure to include interventions for actual skin breakdown in the baseline care plan. This was found to be evident for one of three residents (Resident #135) reviewed for possible pressure ulcers.
  6. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on medical record review and staff interview, it was determined the facility 1) failed to follow a resident's care plan related to activities of daily living (ADL), 2a) failed to follow a resident care plan related to monitoring for psychotropic drug side effects, 2b) failed to develop and implement comprehensive, person-centered care plans with non-pharmacological approaches to care for a resident receiving psychotropic medication, and 3) failed to implement the use of fall mats as indicated in the resident's fall care plan. This was evident for one (Resident #132) of two residents reviewed for discharge; one (Resident #17) of five resident's reviewed for unnecessary medications; and one of six residents (Resident #64) reviewed for accidents.
  7. D
    Provide care and assistance to perform activities of daily living for any resident who is unable.
    F677 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on observation, record review and staff interview, it was determined that the facility failed to provide Activities of Daily Living (ADL) for a resident who required assistance from staff for bathing. This was evident for 1 (Resident #132) of 2 residents reviewed for discharge.
  8. D
    Provide activities to meet all resident's needs.
    F679 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on observation, family interview, record review, and staff interview, it was determined that the facility staff failed to provide activities for a resident who required individual activities in their room. This was evident for 1 (Resident #22) of 2 residents reviewed for activities.
  9. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wrote2) On 10/09/19 at 10:14 AM, Resident #4 was observed to be wearing a wanderguard. Review of the resident's medical record revealed diagnosis of dementia and delusions. A wanderguard is a device, that the resident wears like a braclet on either the writst or ankle, that alarms when the resident is within a certain distance from an exit. On 10/11/19 at 9:20 AM, review of the resident's medical record revealed orders to check the Wanderguard function every morning and to check the placement every shift. Both of these orders were in effect since June 2018. Review of the treatment administration record (TAR) revealed the order to Check Wanderguard function in the morning was scheduled for 6:00 AM indicating this check should be completed by the night shift nurse. [...]
  10. 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.
    F758 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to ensure that a resident's medication regimen was free from unnecessary medication by failing to ensure that 1) psychotropic medication prescribed as needed included the frequency the medication could be administered and 2) that the psychotropic order was limited to 14 days or had a specific duration, with rationale for an extended time period documented in the medical record, and 3) failed to monitor a resident for side effects related to the use of antidepressant medications. This was evident for 1 (Resident #17) of 5 residents reviewed for unnecessary medications.
  11. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) November 20, 2019
    Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to keep complete and accurate medical records as evidenced by having two conflicting Maryland Medical Order for Life Sustaining Treatment (MOLST) forms in the electronic health record. This was evident for 1 (Resident #83) of 3 closed records reviewed. The MOLST documents a person's wishes regarding cardiopulmonary resuscitation (CPR) and other life-sustaining treatments.
May 18, 2018Standard inspection · 7 citations
  1. E
    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.
    F726 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, pattern · Corrected (the home has a date of correction) July 13, 2018
    Inspectors wroteBased on review of employee files and interview with staff it was determined that the facility failed to have a system in place to ensure that all geriatric nursing assistants (GNA) and certified medicine aides (CMA) were able to demonstrate competency in skills and techniques necessary to care for residents This was evident for 7 of 15 GNA and CMA's records (#5, #6, #9, #10, #11, #12 and #13) selected for review.
  2. D
    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
    F656 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 13, 2018
    Inspectors wroteBased on medical record review and staff interview, it was determined that facility staff failed to initiate a Care Plan for a bowel regimen. This was true for 1 of 1 residents (#47) reviewed for bowel regimen.
  3. D
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    F684 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 13, 2018
    Inspectors wroteBased on observations, medical record review and interview with facility staff, it was determined the facility failed to 1. apply Geri sleeves to the Bilateral Lower Extremities as ordered by the physician (#131) and 2. document a change in condition assessment (#81). This was evident for 2 of 37 residents reviewed.
  4. D
    Provide enough food/fluids to maintain a resident's health.
    F692 · Quality of Life and Care · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 13, 2018
    Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to complete an annual nutritional assessment following a significant weight loss. This was evident for 1 of 5 residents (#12) reviewed for nutrition during this annual survey.
  5. D
    Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
    F711 · Nursing and Physician Services · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 13, 2018
    Inspectors wroteBased on medical record review and interview, the physician's nurse practitioner failed to 1. document current medications accurately (Resident #1 and #55) and 2. have psychiatry visit notes available in a timely manner. This was evident for 3 of 37 residents reviewed in the final sample.
  6. D
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    F757 · Pharmacy Service · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 13, 2018
    Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility staff failed to indicate a rationale for the continued use of a cognitive-enhancing medication for Resident #65. This was evident for 1 of 37 residents reviewed.
  7. D
    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
    F842 · Resident Assessment and Care Planning · No actual harm, potential for more than minimal harm, isolated · Corrected (the home has a date of correction) July 13, 2018
    Inspectors wroteBased on medical record review of facility documentation and interview with facility staff, it was determined that the facility failed to ensure and/or maintain accurate medical records for residents (#31 and #65). This was evident for 2 of 37 residents reviewed in the final sample.

Fire safety inspections

35 fire safety citations on file: 5 on June 27, 2025, 19 on November 22, 2024, 10 on October 11, 2019, 1 on May 18, 2018.

Every fire safety citation35 citations
  1. F
    Develop and maintain an Emergency Preparedness Program (EP).
    E 4 · June 27, 2025 · Corrected (the home has a date of correction)
  2. F
    Conduct risk assessment and an All-Hazards approach.
    E 6 · June 27, 2025 · Corrected (the home has a date of correction)
  3. F
    Address patient/client population and determine types of services needed.
    E 7 · June 27, 2025 · Corrected (the home has a date of correction)
  4. F
    Include a process for Emergency Preparedness collaboration.
    E 9 · June 27, 2025 · Corrected (the home has a date of correction)
  5. F
    Address subsistence needs for staff and patients.
    E 15 · June 27, 2025 · Corrected (the home has a date of correction)
  6. F
    Meet other general requirements.
    K 100 · November 22, 2024 · Corrected (the home has a date of correction)
  7. F
    Provide properly protected cooking facilities.
    K 324 · November 22, 2024 · Corrected (the home has a date of correction)
  8. F
    Install a fire alarm system that can be heard throughout the facility.
    K 341 · November 22, 2024 · Corrected (the home has a date of correction)
  9. F
    Have approved installation, maintenance and testing program for fire alarm systems.
    K 345 · November 22, 2024 · Corrected (the home has a date of correction)
  10. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · November 22, 2024 · Corrected (the home has a date of correction)
  11. F
    Have simulated fire drills held at unexpected times.
    K 712 · November 22, 2024 · Corrected (the home has a date of correction)
  12. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · November 22, 2024 · Corrected (the home has a date of correction)
  13. F
    Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
    K 914 · November 22, 2024 · Corrected (the home has a date of correction)
  14. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · November 22, 2024 · Corrected (the home has a date of correction)
  15. E
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · November 22, 2024 · Corrected (the home has a date of correction)
  16. 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 · November 22, 2024 · Corrected (the home has a date of correction)
  17. E
    Have properly located and lighted "Exit" signs.
    K 293 · November 22, 2024 · Corrected (the home has a date of correction)
  18. E
    Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
    K 321 · November 22, 2024 · Corrected (the home has a date of correction)
  19. E
    Install an approved automatic sprinkler system.
    K 351 · November 22, 2024 · Corrected (the home has a date of correction)
  20. E
    Have properly installed electrical wiring and gas equipment.
    K 511 · November 22, 2024 · Corrected (the home has a date of correction)
  21. E
    Have proper medical gas storage and administration areas.
    K 923 · November 22, 2024 · Corrected (the home has a date of correction)
  22. D
    Install emergency lighting that can last at least 1 1/2 hours.
    K 291 · November 22, 2024 · Corrected (the home has a date of correction)
  23. D
    Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
    K 362 · November 22, 2024 · Corrected (the home has a date of correction)
  24. D
    Install corridor and hallway doors that block smoke.
    K 363 · November 22, 2024 · Corrected (the home has a date of correction)
  25. F
    Inspect, test, and maintain automatic sprinkler systems.
    K 353 · October 11, 2019 · Corrected (the home has a date of correction)
  26. F
    To conduct inspection, testing and maintenance of fire doors by qualified individuals.
    K 761 · October 11, 2019 · Corrected (the home has a date of correction)
  27. F
    Have a battery powered remote alarm panel in a location accessible by operating personnel.
    K 916 · October 11, 2019 · Corrected (the home has a date of correction)
  28. F
    Have generator or other power source capable of supplying service within 10 seconds.
    K 918 · October 11, 2019 · Corrected (the home has a date of correction)
  29. E
    Install an approved automatic sprinkler system.
    K 351 · October 11, 2019 · Corrected (the home has a date of correction)
  30. D
    Keep aisles, corridors, and exits free of obstruction in case of emergency.
    K 211 · October 11, 2019 · Corrected (the home has a date of correction)
  31. D
    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 · October 11, 2019 · Corrected (the home has a date of correction)
  32. D
    Have exits that are accessible at all times.
    K 271 · October 11, 2019 · Corrected (the home has a date of correction)
  33. D
    Properly select, install, inspect, or maintain portable fire extinguishes.
    K 355 · October 11, 2019 · Corrected (the home has a date of correction)
  34. D
    Install corridor and hallway doors that block smoke.
    K 363 · October 11, 2019 · Corrected (the home has a date of correction)
  35. D
    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 · May 18, 2018 · Corrected (the home has a date of correction)

Fines and payment denials

CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.

Staffing

Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.

MeasureThis homeMarylandUnited States
All nursing staff (RN, LPN and aides)3.333.873.86
Registered nurses0.580.840.69
All nursing staff on weekends3.053.473.42
Nurse aides2.04
Licensed practical nurses0.71
Nursing staff turnover (share who left in a year)44.4%40.2%45.8%
Registered nurse turnover40.0%38.7%42.9%
Administrators who left1

CMS expects 4.25 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.

Staffing by quarter, from daily payroll records

Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.44 on weekdays and 3.05 on weekends, 11% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 0.0% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.41 in April to June 2025 to 3.33 in January to March 2026.

QuarterAll nursing staffRegistered nursesWeekdaysWeekendsContract staff shareDays with no RN hoursResidents a day
Jan to Mar 20263.330.583.443.05 0.0%0 of 9085
Oct to Dec 20253.230.623.323.01 0.0%0 of 9283
Jul to Sep 20253.340.693.373.28 0.0%0 of 9280
Apr to Jun 20253.410.643.543.09 0.0%0 of 9176
United States, Jan to Mar 20263.750.623.923.335.3%0.5% of days
Maryland, Jan to Mar 20263.730.743.883.348.0%0.1% of days

Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.

Staff pay reports

Staff pay at this home

No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review.

Official wage estimates for Maryland

JobMedianMiddle halfEmployed
Maryland, all employers
CNAs (nursing assistants)$20.79$18.46 to $22.0027,720
LPNs and LVNs$35.89$31.40 to $38.309,560
Registered nurses$47.98$40.26 to $51.6152,910
United States, nursing care facilities
CNAs (nursing assistants)$20.67$17.91 to $22.55534,270
LPNs and LVNs$33.86$30.05 to $37.40188,210
Registered nurses$41.11$37.85 to $47.68142,270

Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.

How staff pay reports work · CNA pay by state

Quality measures

The measures CMS uses for the quality star. Lower is better for every one of them.

MeasureThis homeMarylandUS
Percentage of long-stay residents whose need for help with daily activities has increased
Long Stay residents, 2025Q2-2026Q1
21.820.413.9
Percentage of long-stay residents with a catheter inserted and left in their bladder
Long Stay residents, 2025Q2-2026Q1
1.90.50.8
Percentage of long-stay residents with a urinary tract infection
Long Stay residents, 2025Q2-2026Q1
1.51.51.6
Percentage of long-stay residents experiencing one or more falls with major injury
Long Stay residents, 2025Q2-2026Q1
5.02.43.2
Percentage of short-stay residents who newly received an antipsychotic medication
Short Stay residents, 2025Q2-2026Q1
6.71.11.6
Percentage of long-stay residents whose ability to walk independently worsened
Long Stay residents, 2025Q2-2026Q1
24.722.214.1
Percentage of long-stay residents with pressure ulcers
Long Stay residents, 2025Q2-2026Q1
3.95.94.6
Percentage of long-stay residents who received an antipsychotic medication
Long Stay residents, 2025Q2-2026Q1
38.113.815.4
Percentage of short-stay residents who were rehospitalized after a nursing home admission
Short Stay residents, 20250101-20251231
22.621.023.8
Percentage of short-stay residents who had an outpatient emergency department visit
Short Stay residents, 20250101-20251231
15.89.812.0
Number of hospitalizations per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.61.31.9
Number of outpatient emergency department visits per 1000 long-stay resident days
Long Stay residents, 20250101-20251231
1.21.21.8

Short-term rehab results

For a stay to recover after a hospital visit, these are the results CMS publishes for Caroline Nursing and Rehab's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (54.9% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.

Went home or back to the community

54.9% this home

No different from the national rate

US median of homes 51.5% · Maryland: 90 better, 29 worse

Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 137 eligible stays.

Potentially preventable readmissions

11.3% this home

No different from the national rate

US median of homes 10.7% · Maryland: 0 better, 41 worse

Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 169 eligible stays.

Infections that led to a hospital stay

7.8% this home

No different from the national rate

US median of homes 7.1% · Maryland: 5 better, 6 worse

Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 92 eligible stays.

Self-care and mobility at discharge

69.3% this home

Median of homes: Maryland61.2% · US 56.6%

Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 75 residents counted.

Falls with major injury

1.9% this home

Median of homes: Maryland0.4% · US 0.0%

Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 108 residents counted.

New or worsened pressure ulcers

1.4% this home

Median of homes: Maryland2.4% · US 1.7%

Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 108 residents counted.

Medication list given at discharge

Not reported

CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.

Median of homes: Maryland98.1% · US 98.7%

Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 5 residents counted.

Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.

Owners and operators

Legal business name: 520 KERR AVENUE OPCO LLC. CMS links this home to Key Health Management, a group of 7 nursing homes averaging 1.7 stars overall.

NameRoleTypeShareSince
Caroline Operations Holdco LLCDirect ownership interestOrganization08/01/2022
Md2 Investors LLCIndirect ownership interestOrganization08/01/2022
Hirth, YechielIndirect ownership interestIndividual08/01/2022
Caroline Property Holdco LLC5% or greater mortgage interestOrganization08/01/2022
Hirth, YechielCorporate officerIndividual08/01/2022
Fisher Yohn, CarlaOperational/managerial controlIndividual08/19/2024
Hirth, YechielOperational/managerial controlIndividual08/01/2022
Howard, DanielOperational/managerial controlIndividual08/01/2022
Caroline Property Holdco LLCAdp of the SNFOrganization08/01/2022
Key Health Management LLCAdp of the SNFOrganization08/01/2022
Md2 Investors LLCAdp of the SNFOrganization08/01/2022
Ausch, SaraAdp of the SNFIndividual08/01/2022
Eisen, MenasheAdp of the SNFIndividual08/01/2022
Fisher Yohn, CarlaAdp of the SNFIndividual08/19/2024
Hirth, YechielAdp of the SNFIndividual08/01/2022
Howard, DanielAdp of the SNFIndividual08/01/2022
Klein, YehudisAdp of the SNFIndividual08/01/2022
Perlstein, BarryAdp of the SNFIndividual08/01/2022
Schlussel, NaftaliAdp of the SNFIndividual08/01/2022

As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.

Questions to ask on a visit

Chosen from this home's own inspection record.

  1. How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 11 problems in this area, most recently on March 13, 2026: "Provide care and assistance to perform activities of daily living for any resident who is unable."
  2. When is the care plan meeting, and can family attend it?Inspectors cited 9 problems in this area, most recently on October 29, 2025: "Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards."
  3. How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 6 problems in this area, most recently on October 29, 2025: "Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist."
  4. How many nurses and aides work each shift, nights and weekends included?Inspectors cited 5 problems in this area, most recently on November 22, 2024: "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."
  5. Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.05 hours per resident per day, below the Maryland average of 3.47.
  6. How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.

Other nursing homes nearby

Maryland contacts for a concern about a nursing home

These are the official offices in Maryland. NursingHomeClear cannot take or act on complaints.

Common questions

What is Caroline Nursing and Rehab's Medicare star rating?
CMS rates Caroline Nursing and Rehab 2 out of 5 stars overall, with 2 for health inspections, 2 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
How many deficiencies did Caroline Nursing and Rehab get at its last inspection?
13 health deficiencies at the standard inspection on November 22, 2024. The Maryland average is 17.
Has Caroline Nursing and Rehab been fined?
CMS lists no fines in the last three years.
Does Caroline Nursing and Rehab accept Medicaid?
It is certified to take Medicaid (CMS lists it as "Medicare and Medicaid"). Certification does not mean a Medicaid bed is open: ask the admissions office.
Who owns Caroline Nursing and Rehab?
CMS lists 19 owners and managers, and links the home to Key Health Management. Legal business name: 520 KERR AVENUE OPCO LLC.

Sources

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