415 Morgnec Road, Chestertown, MD 21620 · Kent County · (410) 778-1900
92 certified beds, about 88 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1994
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215260 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on August 13, 2025, inspectors cited 38 health deficiencies (the Maryland average is 17, the national average 9.2).
None of its 79 health citations since February 2019 was rated as actual harm or immediate jeopardy.
CMS lists 1 fine totaling $3,418 in the last three years; the largest was $3,418, and the latest is dated January 22, 2024.
Nurses and nurse aides worked 3.38 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.70 of those hours.
53.3% 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.
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.
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 79 health citations on file.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interview, it was determined that the facility failed to ensure residents had a homelike dining environment. This was evident for the initial dining observation during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record reviews, it was determined that facility staff failed to ensure sufficient weekend staffing. This deficient practice was evidenced by the Payroll-Based Journal (PBJ) report review during the annual survey.
Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility 1) failed to maintain kitchen, kitchen equipment and surfaces in a sanitary condition to prevent the potential for food contamination 2) failed to ensure that food items were labeled and dated. This was found to be evident during the observations of the facility's kitchen food service operations during Medicare/Medicaid recertification survey. 1) On 08/04/2025 at 7:43 AM, during the initial facility tour with the Assistant Food Service Director (Staff #1), the surveyor observed five jars of different seasonings on the top shelf, all open, with visible seasoning particles scattered across the shelf. When the surveyor asked why the seasoning jars were not covered, she stated that she had just returned from vacation and that the night staff should have kept it covered. [...]
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interview, it was determined that the facility failed to ensure that resident rights are maintained by knocking prior to entering a resident's room. This was evident for 2 of 2 observations on the Chesapeake unit upon facility initial entry.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure that Advanced Beneficiary Notice of Noncoverage (ABN) was provided as required. This was evident for 1 (Resident #99) of 3 residents reviewed for beneficiary notification.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interviews, the facility failed to ensure less restrictive alternatives were attempted and documented prior to administering an additional antipsychotic medication. This deficient practice was evident for 2 (Resident #6 and #69) of 2 residents reviewed for unnecessary medications during a Medicare/Medicaid recertification survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to report an allegation of abuse within two hours. This was evident for 1 (Incident #310745) of 3 Facility Reported Incidents reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record reviews and interviews, it was determined that facility staff failed to ensure electronic transfer forms and bed hold notices were completed in Point Click Care for a resident who was transferred to the hospital. This deficient practice was evident for one resident (#93) reviewed for transfer notices during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure the Minimum Data Sheet (MDS) accurately reflected a resident's status. This was evident for 1 (Resident #5) of 3 residents reviewed for pressure ulcers/wounds.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interviews, it was determined that facility staff failed to provide evidence that a level 1 preadmission screening and resident review (PASARR) was completed prior to admission, or at the time of admission for a resident with a mental disability. This deficient practice was evident for 1 (Resident #6) of 2 residents reviewed for PASARR during the annual survey.
Inspectors wroteBased on record review and interview with facility staff, it was determined that the facility failed to 1) initiate a care plan for residents receiving oxygen therapy, 2) initiate a care plan for a resident with Clostridioides difficile (C. Diff), and 3) initiate a care plan for a resident with colostomy. This was evident for 3 residents (Residents #19, #20 and #98) out of 3 resident records reviewed for care plans during the Medicare/Medicaid recertification survey. A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess, and evaluate the effectiveness of the resident's care. Oxygen (O2) therapy is a treatment that provides you with extra oxygen to breathe in. It is also called supplemental oxygen. It is only available through a prescription from your health care provider. Clostridioides difficile (C. [...]
Inspectors wroteBased on review of a facility reported incident , record reviews and staff interviews, it was determined that the facility failed to 1) revise a care plan to accommodate the need after medication was increased and 2) revise a care plan after a facility reported incident. This was evident for 1 resident (Resident #69) out of 3 residents reviewed for care plans during the Medicare/Medicare recertification survey. The care plan provides an opportunity to see if it meets the residents' needs by reviewing what strategies are working and which are not. It can also identify changes in the resident's condition or behavior that will require revisions of the care plan. Care conferences are usually held on a regular basis, often quarterly, but can be scheduled more frequently if needed based on the resident's condition. [...]
Inspectors wroteBased on record reviews and interviews, it was determined that the facility staff failed to follow physician's orders and professional standards of quality when administering blood pressure medication. This deficient practice was evident for one resident (#9) reviewed for professional standards during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and record reviews, it was determined that the facility staff failed to provide appropriate treatment to maintain the resident's ability to perform activities of daily living. This deficient practice was evident for 1 (Resident #6) of 2 residents reviewed for vision and hearing.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and record reviews it was determined that facility staff failed to assist a resident who was dependent on staff for activities of daily living (ADLs) for showers. This deficient practice was evident for 1 (#38) resident reviewed for ADL care during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews, observations, and record reviews it was determined that staff failed to 1.) adequately monitor and assess urinary output and 2.) ensure pain was assessed and managed per the physician's order. This deficient practice was evident for one Resident (#38) reviewed for quality of care and one (#94) of two residents reviewed for pain management during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure a resident received services consistent with professional standards of practice to prevent new pressure ulcers/wounds from developing. This was evident for 1 (Resident #5) of 3 residents reviewed for pressure ulcers/wounds.
Inspectors wroteBased on surveyor observation, review of the medical record, and interview with facility staff, it was determined the facility staff failed to provide residents with respiratory care consistent with professional standards by 1) failing to date and label the oxygen tubing, nasal cannula and the humidifier bottle and 2) failing to follow the physicians' order for the oxygen administration. This was evident for 1 resident (Resident #19) out of 1 resident observed on oxygen therapy during the Medicare/Medicaid recertification survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure 1) pain management was provided to a resident based on professional standards of practice and the comprehensive person-centered care plan, and 2) adequate pain management by assessing pain as ordered. This was evident for 2 (Resident #8 and #94) of 2 residents reviewed for pain management.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, it was determined that the facility failed to ensure that the physician reviewed a resident's total plan of care at each visit. This was evident for 1 (Resident #8) of 2 residents reviewed for hospitalization during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and record reviews, it was determined that the facility staff failed to conduct annual nursing aide performance reviews. This was evident for 5 out of 5 nursing aide performance appraisals, reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interviews, it was determined that facility staff failed to post the actual hours worked per shift for Registered Nurse (RN), Licensed Practical Nurse (LPN), Certified Medication Aide (CMA), Geriatric Nursing Assistant (GNA). This deficient practice was evident for 2 (Chesapeake and [NAME]) out of 2 units reviewed for posted nurse staffing information.
Inspectors wroteBased on observation, review of narcotic record books and interviews with facility staff, it was determined that the facility failed to ensure narcotic record books were consistently signed by both incoming and outgoing nurses. This was evident for 5 out of 5 narcotic books reviewed during the facility's Medicare/Medicaid recertification survey. On 08/05/2025 at 7:40 AM, during a medication administration observation on the [NAME] Unit, the surveyor reviewed the narcotic record book and noted multiple missing signatures dating back to May 2025. More recent omissions included the weekend shifts from 08/01/2025 through 08/03/2025. At 7:44 AM on 08/05/2025, the unit manager Staff #5 was called for dual observation. She confirmed the missing signatures. [...]
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and staff interviews, it was determined that the facility failed to ensure that resident Medication Regimen Review (MRR) recommendations were addressed by the provider. This was evident for 3 (Resident #5, #6, and #69) of 5 residents reviewed for unnecessary medications.
Inspectors wroteBased on medical record review and interviews with facility staff, it was determined that the facility failed to ensure residents were free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #69) out of 2 residents reviewed for unnecessary medications during the facility's Medicare/Medicaid recertification survey.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure the 1) appropriate labeling and storage of medications and 2) appropriate temperature monitoring was maintained for the medication refrigerator. This was evident in 2 out of 5 medication carts observed and 1 out of 2 medication storage rooms observed during the facility's Medicare/Medicaid recertification survey. House Stock Medications are medications kept readily available on-site for general use by residents or patients, not specifically ordered for an individual. 1) On 08/05/2025 at 10:06 AM, during a medication administration observation on the [NAME] Unit, the surveyor observed one opened bottle each of Melatonin tablets, Vitamin B12 tablets, Magnesium Oxide tablets, and Guaifenesin extended-release expectorant that were not dated. [...]
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and record reviews, it was determined that facility staff failed to refer a resident with worn down dentures for dental services in a timely manner. This deficient practice was evident for one resident (#10) reviewed for dental services during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record reviews and interviews, it was determined that the facility staff failed to ensure 1) resident medical records were complete and accurate, and 2) resident medical records were maintained. This was evident for 3 (Resident #5, #6, and #80) of 4 residents reviewed for Preadmission Screening and Resident Review (PASARR), and 1 (Resident #97) of 42 residents reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation and interview, it was determined that the facility failed to ensure linen was stored and processed to prevent the spread of infection. This was evident during 1 of 1 observation of the laundry room.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure residents had or were screened for the pneumococcal and influenza vaccinations as indicated. This was evident for 2 (Resident #43, #78) out of 5 residents screened for immunizations.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that each resident was screened for and offered the COVID- 19 vaccination. This was evident for 2 (Resident #43, #78) out of 5 residents screened for immunizations.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations and interviews, it was determined that the facility failed to ensure a safe and comfortable environment for residents and staff. This was evident during observations on the Chesapeake and [NAME] units during the annual survey.
Inspectors wroteBased on observations and interviews with the facility staff, it was determined that the facility failed to ensure effective pest control measures were implemented to prevent and control flies in food service and resident care areas. This was found to be evident during the observations of the facility's kitchen food service operations and in two residents (Resident #84 and #78) rooms during Medicare/Medicaid recertification survey. On 08/04/2025 at 7:44 AM, a surveyor observed multiple flies flying around Resident #84's room (room [ROOM NUMBER]) while the resident was resting in bed. When the surveyor asked if flies were often present, Resident #84 replied, Yes. On 08/04/2025 at 7:51 AM, during the continued initial tour of the kitchen, this surveyor observed multiple flies inside the kitchen. [...]
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide staff with the required Quality Assurance and Performance Improvement (QAPI) training. This deficient practice was evident for 7 out of 7 employee files reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide staff with mandatory infection prevention and control training. This deficient practice was evident for 7 out of 7 employee files reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide staff with compliance and ethics training. This deficient practice was evident for 7 out of 7 employee files reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide geriatric nursing assistants (GNA) with the required annual in-service training. This deficient practice was evident for 5 out of 5 GNA files reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interviews and administrative record reviews, it was determined that the facility failed to provide staff with dementia training. This deficient practice was evident for 7 out of 7 employee files reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review and interview, it was determined that the facility failed to ensure that a resident was free from abuse. This was evident for 1 (Incident #310745) of 3 Facility Reported Incidents (FRIs) reviewed during the annual survey.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record reviews and interviews, it was determined that facility staff failed to ensure a thorough investigation was conducted for an allegation of staff to resident abuse and failed to maintain documentation. This deficient practice was evident for one resident (# 78) reviewed for facility reported investigations during the annual survey.
Inspectors wroteBased on the review of Complaint Number 310737, medical records, and interviews with facility staff, it was determined that the facility failed to ensure proper colostomy care was provided and documented for a resident (Resident #98), who had a colostomy. This deficiency was identified during the complaint investigation at the facility's Medicare/Medicaid recertification survey An ostomy is a surgery that makes a temporary or permanent opening in the skin called a stoma. A stoma is a pathway from an internal organ to the outside of your abdomen. A colostomy is a surgical procedure that brings one end of the large intestine out through an opening (stoma) made in the abdominal wall. Stools moving through the intestine drain through the stoma into a bag attached to the skin of the abdomen. [...]
Inspectors wroteBased on record review and staff interview it was determined that the facility staff failed to develop and implement policies and procedures for a Quality Assurance Performance Improvement (QAPI) program to ensure that residents received quality care that was safe and effective. This was evident throughout the survey and has the potential to affect all residents residing in the facility.
Inspectors wroteBased on observation, interviews, records reviews, and staff interviews, the facility failed to provide and maintain a clean, comfortable/homelike environment for all residents of the facility. This was evident throughout the facility impacting all residents.
Inspectors wroteBased on medical record review, interviews, and observations it was determined that the facility staff failed to 1.) provide twice weekly showers to residents 3 (#7, #10, #16) of 24 residents reviewed per the residents' schedule, individual needs, and preferences and 2.) provide working telephones to all the residents. This was evident for 48 of 76 residents.
Inspectors wroteBased on observation, medical record review and staff interview it was determined the facility failed to ensure a resident was free of significant medication error as evidenced by failure of the nurse to verify the correct dosage of a medication prior to administration. This was evident for 1 (Resident # 8) of 5 residents reviewed during the survey for medications.
Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to document adequately on the dishwasher and three compartment sink logs, properly label and store food to ensure the food is properly maintained and does not expire and prevent flies from entering the stored food. This was found to be evident during an initial tour of the facility during the facility's Medicare/Medicaid survey.
Inspectors wroteBased on resident interview and observation it was determined the facility staff failed to treat residents with respect and dignity. This was evident for 4 (#16, #48 #75, #228) of 24 residents reviewed during the survey.
Inspectors wroteBased on observation and interview it was determined that the facility failed to provide written notice to a resident prior to changing the room assignment and failed to provide the resident with room assignment options. This deficient practice was evidenced in 1 (#228) of 2 resident records reviewed for room assignment changes.
Inspectors wroteBased on observation, staff, resident interview and review of facility policy and procedure it was determined the facility failed to provide the ability for Resident (#58) to have access to his/her personal funds on the same day funds were requested. This was evident for 1 resident (#58) out of 58 residents reviewed during the annual survey.
Inspectors wroteBased on observations and interviews with the resident and facility staff it was determined the facility staff failed to ensure that the resident right to privacy was maintained by delivering mail unopened to the resident. This was found to be evident for 1 (Resident # 46) of 58 residents reviewed during the survey.
Inspectors wroteBased on record review and interview it was determined the facility failed to give Resident #49 at least 48 hours' notice before the end of his/her Medicare covered Part A facility stay. This was evident for 1 resident (#49) out of 3 residents reviewed for discharges during the survey.
Inspectors wroteBased on administrative record review and interviews with facility staff it was determined the facility failed to keep a resident safe from verbal abuse. This was found to be evident for 1 (Resident # 176) of 12 residents reviewed for abuse during the facility's survey.
Inspectors wroteBased on observations, interviews with the resident family and facility staff, it was determined the facility failed to report allegations of abuse immediately to the state agency. This was found to be evident for 1 (Resident # 51) of 12 residents reviewed for abuse during the facility's Medicare/Medicaid survey.
Inspectors wroteBased on record reviews and interviews it was determined the facility failed to complete a thorough investigation of an alleged employee to resident verbal and physical abuse incident and failed to report the alleged physical and verbal abuse to the police. This deficient practice was evident for 1 (#54) of 12 residents reviewed for alleged abuse during the survey.
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 #48) of 3 residents reviewed for transfers.
Inspectors wroteBased on record review and interviews it was determined that the facility failed to have Quarterly care plan meetings as required for resident (#52) and failed to update the resident care plan to include the resident is non-compliant with treatment regimen (#46). This was evident for 2 of 58 residents (#52 and #46) reviewed during the survey.
Inspectors wroteBased on the medical record review and staff interview it was determined the facility failed to ensure that medication was administered to a resident within a timeframe of professional standards of practice. This was evident for 1 resident (#330) out of 10 residents reviewed for medications during the survey. The Findings Include: Metoprolol Succinate ER (Extended Release) and Lisinopril are medications that are used to treat Hypertension (high blood pressure) to lower a person's blood pressure. Digoxin (Digoxin) is a medication that is used to treat Atrial fibrillation (AFIB) (irregular heart rhythm) to manage a person's heartbeat. Review of resident #330's medical record on 09/25/2023 at 01:49 PM revealed the following: 1. [...]
Inspectors wroteBased on medical record review, interviews with family, observations, interviews with facility staff and a review of facility video footage, it was determined the facility failed to supervise residents with wandering and known aggressive behaviors. This was evident for 3 residents (#51, #33 and #9) of 58 residents reviewed during the survey.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to have an effective system in place to ensure communication of assessment information was conveyed between the nursing facility and the offsite dialysis center. This was found to be evident for 1 of 1 resident (#10) reviewed for dialysis.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure staffing information was complete and accurate. This deficient practice was evident for 1 of 2 units observed during the Medicare/Medicaid survey.
Inspectors wroteBased on a review of the medical record and interviews with facility staff it was determined that the facility failed to respond to the pharmacy recommendations after a monthly clinical review was done. This was found to be evident for 1 (Resident # 46) of 5 residents reviewed for unnecessary medications during the facility's Medicare/Medicaid survey.
Inspectors wroteBased on medical record review and interviews it was determined that the facility physician prescribed an antibiotic to a resident without adequate indication of use. This deficient practice was evident in 1 (#226) of 5 resident records reviewed for unnecessary medications.
Inspectors wroteBased on medical record review and interviews with facility staff, it was determined the facility failed to keep a resident free from unnecessary psychotropic medications. This was found to be evident for 1 (Resident #7) of 5 residents reviewed for unnecessary medications during the facility's recertification survey.
Inspectors wroteBased on medication administration observation, medical record review, and staff interview, it was determined the facility staff failed to ensure a medication error rate of less than 5%. This was evidenced by 7 errors observed during the medication administration of 25 opportunities for errors, that resulted in a medication error rate of 28%. This was found to be evident for 1 resident (R #8) out of 5 residents observed during the medication administration.
Inspectors wroteBased on record review and staff interview it was determined the facility failed to secure a narcotic medication and limit access to unauthorized persons. This was evident for 1 resident (#329) out of 5 residents reviewed for medications during the annual survey.
Inspectors wroteBased on observations and administrative record reviews and interviews with facility staff it was determined the facility failed to ensure that the Dietary Manager License was active and not expired. This was found to be evident when the survey team reviewed the Dietary Manager credentials during the facility's Medicare/Medicaid survey.
Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that menus were being followed when preparing food for the residents. This was found to be evident when observations were made of the kitchen during the facility's Medicare/Medicaid survey.
Inspectors wroteBased on observation, record review, and interviews it was determined that the facility staff failed to: 1.) document the temperature of the refrigerator on the unit [NAME] and 2.) ensure that staff documented while providing one to one monitoring for a resident (#9) with known aggressive behaviors. This was evident for 1 of 2 units observed and 1 of 58 residents reviewed during the survey.
Inspectors wroteBased on observation and staff interview it was determined that the facility failed to correctly store clean personal protective equipment for resident's rooms (#109, #404) to prevent infection and failed to use infection control practices while providing wound care to a resident (#226). This was true for 1 of 58 residents reviewed during the survey and 2 resident rooms.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to offer all residents the opportunity to receive the pneumococcal vaccines. This deficient practice was evident in 1 (#51) out of 5 resident records reviewed for required vaccines.
Inspectors wroteBased on record review and staff and Responsible Party interviews it was determined the facility failed to notify 1) a court appointed guardian when Resident #5 developed a pressure injury; and 2) the Responsible Party when Resident #122 had a change in condition. This was evident regarding Resident #5 for 1 of 3 residents investigated for pressure ulcers/injuries during the survey and regarding Resident #122 this was evident for 1 of 8 residents reviewed during the survey process.
Inspectors wroteBased on the medical record and staff interviews, the facility staff failed to send the Care Plans with Residents #54, #71 and #73 when they were sent to the hospital. This was evident for 3 of 3 residents reviewed for hospitalization during the survey.
Inspectors wroteBased on the medical record and staff interviews, the facility staff failed to provide necessary written notices for Resident #54, or the Resident's responsible party, of a transfer out of the facility. This was evident for 1 out of 3 residents investigated for hospitalization during the survey process.
Inspectors wroteBased on the medical record and staff interviews, the facility staff failed to provide the required written notice to Resident #54, or the resident's responsible party, of the bed hold policy during a transfer out of the facility. This was evident for 1 out of 3 residents investigated for hospitalization during the survey process.
Inspectors wroteBased on record review and interview with staff the facility failed to implement a baseline care plan for Resident #221. This was evident for 1 out of 29 residents.
Inspectors wroteBased on medical record review and resident and staff interview it was determined that the facility failed to develop a care plan for pain management for Resident #52. This was evident for 1 of 29 residents investigated during the survey.
Inspectors wrote2) 02/14/19 11:01 AM Resident # 221 was admitted to the facility on [DATE] for rehabilitation after suffering a broken right ankle. During the interview process of the survey, it was noted that the resident had edema noted on bilateral lower legs. The edema had not been addressed by the physician or staff. There were no medications for the edema and no care plan. The admission assessment dated [DATE] indicated that the resident had edema noted on the right lower leg. On 2/14/19, staff # 6 went into the resident's room and assessed the resident. The resident was found to have 2 plus edema on the right lower leg and 3 to 4 plus edema on left lower leg. A call was placed to the Doctor (Dr.) by staff member #6. The Dr. came into the facility on 2/14/19 after surveyor intervention and assessed the resident. [...]
Inspectors wroteBased on observation and staff interviews it was determined that the facility failed to ensure that: 1) An accurate refrigerator temperature log was kept in the month of January 2019. 2) Facility staff members followed infection control practices in the kitchen area. This practice has a potential of effecting all residents in facility.
Inspectors wroteBased on medical record review and staff interview it was determined that the facility staff failed to keep a complete and accurate medical record. Specifically, the facility failed to document a resident's fall in the facility. This was evident in 1 out of 7 medical records reviewed involving resident's (R#122) during the survey process.
28 fire safety citations on file: 14 on September 28, 2023, 8 on February 15, 2019, 6 on October 19, 2017.
| Date | Penalty | Amount or length |
|---|---|---|
| January 22, 2024 | Fine | $3,418 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Maryland | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.38 | 3.87 | 3.86 |
| Registered nurses | 0.70 | 0.84 | 0.69 |
| All nursing staff on weekends | 3.25 | 3.47 | 3.42 |
| Nurse aides | 2.03 | ||
| Licensed practical nurses | 0.64 | ||
| Nursing staff turnover (share who left in a year) | 53.3% | 40.2% | 45.8% |
| Registered nurse turnover | 53.3% | 38.7% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.30 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
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 3.43 on weekdays and 3.25 on weekends, 5% 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 3.05 in April to June 2025 to 3.38 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.38 | 0.70 | 3.43 | 3.25 | 0.0% | 0 of 90 | 88 |
| Oct to Dec 2025 | 3.16 | 0.75 | 3.20 | 3.05 | 0.0% | 0 of 92 | 90 |
| Jul to Sep 2025 | 3.11 | 0.67 | 3.17 | 2.96 | 0.0% | 0 of 92 | 88 |
| Apr to Jun 2025 | 3.05 | 0.62 | 3.11 | 2.88 | 0.0% | 0 of 91 | 86 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Maryland, Jan to Mar 2026 | 3.73 | 0.74 | 3.88 | 3.34 | 8.0% | 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
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.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Maryland, all employers | |||
| CNAs (nursing assistants) | $20.79 | $18.46 to $22.00 | 27,720 |
| LPNs and LVNs | $35.89 | $31.40 to $38.30 | 9,560 |
| Registered nurses | $47.98 | $40.26 to $51.61 | 52,910 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
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.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Maryland | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 12.7 | 20.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.7 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.0 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.3 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 2.6 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 15.6 | 22.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.4 | 5.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 17.2 | 13.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 12.6 | 21.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 20.2 | 9.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 0.5 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 2.1 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Chestertown Nursing and Rehab's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (41.1% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
41.1% this home
Worse than 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. 107 eligible stays.
14.2% this home
Worse than 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. 137 eligible stays.
8.2% 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. 82 eligible stays.
60.8% 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. 74 residents counted.
0.9% 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. 109 residents counted.
1.9% 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. 109 residents counted.
100.0% this home
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. 24 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.
Legal business name: CHESTERTOWN NURSING AND REHAB, LLC. CMS links this home to Key Health Management, a group of 7 nursing homes averaging 1.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Md4 Holdco, LLC | 5% or greater direct ownership interest | Organization | 100% | 04/01/2023 |
| Md5 Investors LLC | Indirect ownership interest | Organization | 04/01/2023 | |
| Hirth, Yechiel | Indirect ownership interest | Individual | 04/01/2023 | |
| Hirth, Yechiel | Corporate officer | Individual | 04/01/2023 | |
| Hershey, Theresa | Operational/managerial control | Individual | 05/01/2024 | |
| Hirth, Yechiel | Operational/managerial control | Individual | 04/01/2023 | |
| Howard, Daniel | Operational/managerial control | Individual | 04/01/2023 | |
| Ausch, Sara | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/09/2025 | |
| Eisen, Menashe | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/09/2025 | |
| Klein, Yehudis | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/09/2025 | |
| Perlstein, Barry | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/09/2025 | |
| Schlussel, Naftali | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 04/09/2025 | |
| Key Health Management LLC | Adp of the SNF | Organization | 04/01/2023 | |
| Hershey, Theresa | Adp of the SNF | Individual | 05/01/2024 | |
| Howard, Daniel | Adp of the SNF | Individual | 04/01/2023 |
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.
Chosen from this home's own inspection record.
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