Lions Rehab Center
901 Seton Drive, Cumberland, MD 21502 · Allegany County · (301) 722-6272
101 certified beds, about 80 residents a day · For profit - Corporation · Medicare and Medicaid since 1969
Certified for Medicaid Certified for Medicare
Overall
2 of 5
Health inspections
2 of 5
Staffing
4 of 5
Quality measures
2 of 5
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215073 · See it on Medicare.gov · Compare with other homes
The record in brief
At its most recent standard inspection, on March 27, 2026, inspectors cited 18 health deficiencies (the Maryland average is 17, the national average 9.2).
Of 98 health citations since March 2023, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.41 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.76 of those hours.
38.5% of nursing staff left within the year CMS measured (Maryland average 40.2%).
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.
3103/23
3001/25
805/25
210/25
2003/26
707/26
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 98 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
78D
15E
1F
Potential for minimal harm
0A
1B
1C
July 6, 2026Complaint inspection · 7 citations
- G Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on the review of a facility reported incident interviews, medical record review and review of facility policy, it was determined that the facility staff failed to ensure that medication was administered correctly. These failures led to the findings of actual harm to Resident #7. This was evident during the review of 1 of 1 Residents (#7)
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on record review and interview, it was determined that facility staff failed to ensure residents were free from abuse. This was evident for 1 (#1) of 4 residents reviewed for abuse.
- D Protect each resident from the wrongful use of the resident's belongings or money.
Inspectors wroteBased on the review of a facility reported incident 3054507, medical record review, interview with facility staff, it was determined that the facility failed to ensure that residents medications were secure, maintained and free from misappropriation. This was evident for 1 of 2 (9) residents reviewed for medication misappropriation during a complaint survey.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, it was determined that facility staff failed to report all allegations of abuse to the State Agency (SA) as required. This was evident for 1 (#1) of 4 residents reviewed for abuse.
- D Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Inspectors wroteBased on observation, resident interview, record review, and staff interview, it was determined that facility staff failed to ensure that residents had behavioral health services to help achieve their highest practical level of functioning. This was 1 (#1) of 1 resident reviewed for behavioral health concerns.
- D Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to follow the physician's ordered therapeutic diet for their residents. This was evident for 1 (#5) of 1 resident reviewed for dietary services.
- B Post nurse staffing information every day.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to post nursing staffing for the entire building. This was observed during the survey.
March 27, 2026Standard inspection, Complaint inspection · 20 citations
- E Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to maintain a safe/clean/comfortable/homelike environment for Residents. This finding was found to be evident in 2 (Resident rooms [ROOM NUMBERS]) out of 15 Resident rooms and in review of an adequate supply of linen which has the potential to affect all Residents in the facility.
- E Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, interviews and record reviews, it was determined that the facility failed to follow appropriate respiratory care and services. This was found to be evident in 4 (Resident #2, 3, 8 and #11) out of 5 Residents reviewed for respiratory care.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review and interviews it was determined that the facility failed to provide a resident with reasonable accommodation of need. This was found evident in 1 (for Resident # 42) of 6 facility-reported incidents reviewed on the survey.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that a Resident's Responsible Party (RP) was notified of changes in a resident's condition. This was evident for 1 (Resident #96) of 3 residents reviewed for wound care during the survey.
- D Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to ensure the personal privacy of a Resident. This finding was found to be evident in 1 (Resident #11) out of 2 Residents reviewed for urinary catheters.
- D Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on review of the facility's investigation report, record review, and interviews, it was determined that the facility failed to protect a resident from verbal abuse and neglect from an employee. This was found evident on 1 (Resident #42) of 4 Residents reviewed for abuse and neglect.
- D Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to obtain a qualifying diagnosis prior to prescribing a psychotropic medication. This was found to be evident in 1 (#97) out of 5 residents reviewed for unnecessary medications.
- D Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to code Minimum Data Set (MDS) assessments accurately. This finding was found to be evident in 2 (Resident #2 and #16) out 8 Residents reviewed for accurate MDS assessments.
- D Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews and record review, it was determined that the facility failed to ensure residents were provided with summaries of their baseline care plans. This was found to be evident for 1 (#99) out of 8 residents reviewed for care planning during the recertification survey.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews and record reviews it was determined that the facility failed to develop and implement comprehensive care plans for Residents. This finding was found to be evident for 3 (Resident #2, 5 and 11) out of 8 Residents reviewed for care plans.
- D Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on observation, interviews and record reviews it was determined that the facility failed to review, update and revise Resident's care plans after Resident's changes in conditions. This finding was found to be evident in 2 (Resident #11 and #95) out of 13 Residents reviewed for care plan timing and revision.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to administer medications according to professional standards procedure. This was evident for 1 (Resident #69) out of 5 residents reviewed for medication administration.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to provide treatments according to a Resident's plan of care. This was found evident of 1 (Resident #96) out of 3 residents reviewed for wound care.
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interviews and record review it was determined that the facility failed to monitor a Resident's hemodialysis access site. This finding was found to be evident in 1 (Resident #2) out of 1 Resident reviewed for dialysis.
- D Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to complete a resident's behavior management documentation. This was evident for 1 (Resident #22) out of 10 residents evaluated for behavioral, mental, and/or emotional health care and services during the recertification survey.
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure medications were administered to a resident as ordered. This was evident for 1 (Resident #70) out 47 residents reviewed during the survey.
- D Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to properly store food in the refrigerator. This was evident during the initial kitchen tour. This had the potential to impact food prepared in the kitchen.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation and interview, it was determined that the facility, 1) failed to provide functioning hand sanitizers, and 2) failed to correctly identify residents requiring transmission based precautions and 3) failed to perform hand hygiene before direct contact with a resident. This was found to be evident for 5 (110, 111, 406, 407, and 409) out of 10 rooms reviewed for hand sanitizers and 1 (104) out of 7 rooms reviewed for correct transmission-based precaution signage, and 1 (Staff #18) out of 1 staff observed for hand hygiene during the recertification survey.
- D Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that the resident's call system functioned properly. This was found to be evident for 2 residents (#32 and #100) out of 11 residents evaluated for call light access during the recertification survey.
- D Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspectors wroteBased on observations and interviews it was determined that the facility failed to maintain a safe/functional/sanitary/comfortable environment for Residents and staff. This finding was found to be evident in 2 (Resident rooms [ROOM NUMBERS]) out of 15 Resident rooms and the Rehabilitation Department reviewed for safe, comfortable environment.
October 29, 2025Complaint inspection · 2 citations
- D Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure accurate dispensing and administration of medications. This was evident for 1 (Resident #5) of 1 resident reviewed for pain management.
- D Ensure that residents are free from significant medication errors.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure residents are free from significant medication errors. This was evident for 1 (Resident #5) of 1 resident reviewed for pain management.
May 29, 2025Complaint inspection · 8 citations
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on record review and interview it was determined that the facility failed to notify resident's physician when medications were held. This was evident for 1 (R#62) of 3 residents reviewed for notification of medications not given during the complaint survey.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview it was determined that the facility failed to complete thorough investigations of allegations of abuse. This was evident for 1 (#MD00217463) of 7 facility reported incidents reviewed during the complaint survey.
- D Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on record review and interviews it was determined that the facility failed to maintain medical records in accordance with professional standards. This was evident for 1 (MD00215206) of 7 facility reported incidents investigated during the complaint survey.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that residents received ordered medications or treatments. This was evident for three (Resident #36, #12, and #3) out of 29 residents reviewed for medical records.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to ensure that a resident's urine collection bag was secured off the floor. This was evident in 1 (Resident #502) of 3 residents reviewed for urinary catheters.
- D Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical review and staff interview, it was determined that the facility failed to document the reasons for administering as-needed (PRN) pain medications, failed to document the pain assessment to include intensity of pain, location of pain, and description of pain, and failed to implement non-pharmacological interventions before administering pain medication to residents. This was evident for 2 (#24 and #64) of 3 residents reviewed for pain management.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure a resident received their medications according to the attending physician's orders. This was evident for 1 (#518) out of 3 residents reviewed for medication regimen review (MRR).
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on record review, observation, and staff interview, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBP) as part of the infection prevention and control program. This was evident for 2 (Resident #40 and Resident #503) of 3 residents reviewed for pressure ulcers.
January 17, 2025Standard inspection, Complaint inspection · 30 citations
- F Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to monitor temperatures for the dishwasher machine to ensure adequate sanitation, and ensure temperatures were checked for mechanical soft and pureed foods before serving. This was evident for 5 of 8 daily dish machine logs and 3 of 13 daily food temperature logs reviewed.
- E Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments 1) were accurately documented and 2) accurately reflected a Resident's status. This was evident for 4 (#60, #24, #64, #75) out of 35 residents reviewed during the survey
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on record review, observation, and interviews, it was determined that the facility failed to ensure that a resident participated in the care plan process and failed to revise a resident's care plan. This was evident for one (#40) of eight residents reviewed for activities of daily living (ADL) and one (#269) of three residents reviewed for care planning during the survey.
- E Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to 1) provide residents with the amount of assistance needed during meals and 2) ensure that residents unable to carry out activities of daily living (ADL) were given incontinence care. This was evident for 5 (#469, #74, #270, #60, #22) of 8 residents reviewed for ADL during the recertification survey.
- E Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to document the reasons for administering as-needed (PRN) pain medications, failed to document pain assessment to include the location of the pain and type of pain, and failed to implement non-pharmacological interventions before administering pain medication to a Resident reporting pain. This was evident for 1 (#24) of 6 Residents reviewed for unnecessary medications and 2 ( #59, #64) of 3 residents reviewed for pain management.
- D Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure resident's urine collection bag was kept in a privacy bag to maintain dignity. This was evident for 2 (#419, #64) of 3 residents reviewed for urinary catheters.
- D Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review, observation, and interviews, it was determined that the facility failed to ensure that call devices were kept within reach of the resident. This was evident for 1 (Resident #40) in 24 residents reviewed during the survey.
- D Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide residents with quarterly statements in writing of their personal funds account managed by the facility. This was evident for one Resident (#22), who was reviewed for personal funds during the survey.
- D Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure they informed residents of their right to formulate an advance directive. This was evident for one resident (#269) who was reviewed for advance directives during the survey.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on staff interviews, and record reviews, it was determined that the facility failed to notify the physician when a medication was held several times for low systolic blood pressure (SBP). This was evident for 1 (Resident #44) of 6 residents reviewed for unnecessary medications.
- D Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interviews and record review, it was determined that the facility failed to implement its abuse policy. This was evident for one ( #3) of two residents who alleged misappropriation of property and filed a grievance.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interviews and record review, it was determined that the facility failed to report an incident of alleged misappropriation of resident's property to the Office of Health Care Quality. This was evident for 1 (Resident #3) of 2 residents who alleged misappropriation of property and filed a grievance.
- D Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Inspectors wroteBased on record review and staff interviews it was determined that the facility failed to ensure essential care upon admission. This was evident for 1 (Resident #71) out of 4 residents reviewed for neglect during the survey.
- D Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to provide a person-centered comprehensive care plan developed and implemented to meet residents' needs. This was evident for 1 (Resident #419) out of 3 residents who were reviewed for care planning during a survey.
- D Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on staff interviews, and record review, it was determined that the facility failed to follow the physician's orders for weights. This was evident for 1 (Resident #44 ) of 6 residents reviewed for unnecessary medications.
- D Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on medical record review and interview it was determined that the facility failed to provide necessary treatment and services to promote healing of pressure ulcers. This was found to be evident for 1 (Resident #75) out of 4 residents reviewed for pressure ulcers during the survey.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, records review and interviews, it was determined that the facility failed to ensure fall mats were in proper placement. This was evident for 1 (Resident #10) in 3 residents reviewed for accidents.
- D Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on record review, interviews,and observations, it was determined that the facility failed to provide appropriate treatment and services for care of residents with indwelling catheter. This was evident for 2 (#64, #419) of 3 residents reviewed for urinary catheters.
- D Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that a resident's care was overseen by a physician. This was evident for 1 (#24) of 6 residents reviewed for unnecessary medications.
- D Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Inspectors wroteBased on medical record review and staff interviews, it was determined that the facility failed to ensure that physician's notes were complete, accurate, signed, and dated at each visit and part of the medical record. This was evident for 2 (#24, #44) of 35 residents reviewed during the survey.
- D Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure nursing staff were competent with their skills set. This was evident for 2 Registered Nurses (RN #19 and RN #3) of 2 nursing staff evaluated for competency.
- D Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Inspectors wroteBased on interview and record review, it was determined the facility did not have a Director of Nursing who worked on a full-time basis. This was evident during the recertification survey and had the potential to impact all residents, staff, and visitors.
- D Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on medical record review and interviews, it was determined that the facility failed to ensure that Irregularities identified by the pharmacist were reviewed and acted upon timely by the attending physician and failed to develop policies and procedures for the monthly Medication Regimen Review (MRR) to include time frames for the different steps in the process. This was evident for one (#24) of 6 Residents reviewed for unnecessary medications.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to keep residents' drug regimens free from unnecessary medications by failing to ensure residents received their medications according to the attending physician's orders. This was evident for 2 (#59, #44) of 6 residents reviewed for unnecessary medications.
- D Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations, interviews, and record review, it was determined that the facility failed to 1) accurately document the reconciliation of controlled medications and 2) store medications in accordance with professional standards by failing to discard expired medications, failing to date medications when opened, and failing to ensure that medications were not left at a resident's bedside. This was evident for 1 out of 2 narcotic record books reviewed and 1 (#26) out of 35 residents observed during the survey and 2 of 2 medication carts observed.
- D Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on staff interviews and record review, it was determined that the facility failed to have a qualified dietary staff. This was evident for 1 of 1 Director of Food Services.
- D Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Inspectors wroteBased on interview and record review it was determined that the facility failed to comply with State regulations when the facility failed to 1) employ a qualified social worker, 2) monitor employee's relevant health status, 3) provide a minimum of 3 hours of bedside care per occupied bed per day, and 4) ensure the Quality Assurance committee contained the required members. These deficiencies were found during the recertification survey and had the potential to affect all residents, staff and visitors.
- D Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on observations, interviews and record review, it was determined that the facility failed to maintain complete, accurate and legible medical records. This was evident for 3 (#26, #36, #12) out of 35 residents reviewed during the survey.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and pertinent document review, it was determined that the facility failed to: 1) ensure a glucometer was adequately disinfected between different resident uses in a manner that met minimum standards and minimized risk for the infectious spread of blood-borne pathogens, and 2) ensure that Infection Prevention Control Program (IPCP) policies and procedures were reviewed at least annually. This was evident for 1 Resident ( # 26), in a random observation during a recertification/complaint survey.
- D Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide the 2024-2025 COVID-19 immunization to residents and staff. This was evident for 1) five residents (Resident #3, #22, #63, #64, #269) of five residents, and 2) four staff (Staff #3, #24, #25, and #26) of five staff records reviewed for COVID-19 immunization during the recertification survey.
March 22, 2023Standard inspection · 31 citations
- G Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on observation, interview and medical record review, it was determined the facility failed to prevent the development of a stage 4 pressure ulcer, failed to notify the physician when a weekly wound assessment began to indicate potential signs of infection, failed to implement a physician order for a surgical consult, and failed to ensure that a physician or nurse practitioner assessed the pressure ulcer from the time it was first identified as a stage 2 in January of 2022 until May of 2022, at which time the wound specialist assessed the wound as stage 4 ulcer. This was found to be evident for 1 (Resident #51) out of 5 residents reviewed for pressure ulcers. As a result of this failure, actual harm was identified for Resident # 51.
- E Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that advance directives were discussed with residents and/or responsible representatives and orders for life sustaining treatment were voided when new orders were implemented. This was found to be evident for 3 (Resident #27, #46 and #136) out of 6 residents reviewed for advance directives.
- E Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to notify the resident/resident representative in writing of a transfer/discharge of a resident along with the reason for the transfer. This was evident for 4 (#3, #133, #19, and #7 ) of 4 residents reviewed for hospitalization.
- E Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
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 4 (#3, #133, #19, and #7 ) of 4 residents reviewed for hospitalization.
- E Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure the Minimum Data Set assessments accurately reflected the resident's status as evidenced by failure to assess that a resident was receiving dialysis, and incorrectly assessing the resident as having diabetes when there was no supporting evidence to indicate it was a current active diagnosis. This was found to be evident for 2 (Resident # 136 and #7) out of 46 residents reviewed during the survey.
- E Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure the development of a comprehensive person centered care plan as evidenced by failure to develop a care plan to address a resident's needs related to receiving dialysis; failure to develop a care plan for 3 months to address the resident's needs related to a pressure ulcer. This was found to be evident for 3 ( #136, #51, and #21) out of ## residents reviewed during the survey.
- E Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to have an effective system in place to ensure that interdisciplinary team care plan meetings were scheduled to review and revise care plans after each Minimum Data Set (MDS) assessment and failed to update care plans when there were changes in resident needs or preferences. This was found to be evident for 3 (Resident # 133, #7, and #46) out of 43 residents who had care area investigations completed during the survey.
- E Provide activities to meet all resident's needs.
Inspectors wroteBased on medical record review, observation and interview, it was determined that the facility failed to ensure activities to meet the needs of the residents. This was found to be evident for 2 (#46, and #7) out of 5 residents reviewed for activities during the survey.
- E Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Inspectors wroteBased on review of staffing information, complaints allegations, medical records and interviews, it was determined that the facility failed to ensure sufficient nurse staffing. This was found to be evident for 3 of 10 complaints reviewed.
- E Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, medical record review, and interview, it was determined that the facility 1) failed to ensure that nursing staff signed that the controlled drug count was completed at the change of shift as evidenced by missing signatures on the controlled drug count sheets, and pre-signing of the count sheets; 2) failed to account for all narcotics removed from supply as evidenced by documentation of borrowing narcotics and failure to ensure that two staff witnessed wasting of narcotics; 3) failed to ensure that medications were kept secure in the medication cart as evidenced by the observation of two syringes with insulin in them that were observed on top of an unattended medication cart located in a hallway that residents and visitors would be able to access; and 4) failure to ensure that a medication refrigerator was kept at an acceptable temperature. [...]
- D Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Inspectors wroteBased on observation, record review, and interview, it was determined that facility staff failed to ensure that residents had the right to choose when to take a shower. This was evident for 2 (#21 and #19) of 21 residents reviewed for choices.
- D Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on interview and medical record review, it was determined the facility failed to ensure that nursing staff notified the physician that a pressure wound was continuing to worsen and develop possible signs of an infection. This was found for 1 (#51) of 5 residents reviewed for pressure ulcers.
- D Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that residents received the written Notice of Medicare Non-Coverage prior to the date the services were to end. This was found to be evident for one (Resident #132) out of three residents reviewed for beneficiary notification.
- D Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of facility documents and staff interview, it was determined the facility 1) failed to report an allegation of an injury of unknown injury to the State Agency, the Office of Health Care Quality (OHCQ), immediately, but not later than 2 hours after the abuse allegation was made, and 2) failed to report the results of the investigation no later than 5 working days after the incident. This was evident for 2 (#134, #130) of 13 residents reviewed for abuse.
- D Respond appropriately to all alleged violations.
Inspectors wroteBased on review of facility reported incident investigations and interview, it was determined the facility failed to thoroughly investigate allegations of abuse, including an injury of unknown injury. This was evident for 2 (#134, #130) of 13 residents reviewed for abuse.
- D Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to document the information conveyed to a receiving acute care provider when a resident was transferred there emergently. This was evident for 2 (#3, #133) of 4 residents reviewed for hospitalization.
- D Prepare residents for a safe transfer or discharge from the nursing home.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's preparation for a transfer to the hospital. This was evident for 2 (#3, #133) of 4 residents reviewed for hospitalization during the annual survey.
- D Ensure a qualified health professional conducts resident assessments.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure that the individual who completed a portion of the Minimum Data Set assessment signed and ceritified the accuracy of that portion of the assessment. This was found to be evident for 2 (Resident #136, and #7) out of 46 residents reviewed during the survey.
- D PASARR screening for Mental disorders or Intellectual Disabilities
Inspectors wroteBased on record review and interviews, the facility failed to complete a PASSAR during the original admission period for a resident. This was found to be true for 1 (Resident #38) of 3 residents reviewed for PASSARS during the investigation phase of the annual survey.
- D Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure the safety of a cognitively impaired resident by failing to provide adequate supervision as evidenced by the resident was found on the floor 8 times and had 3 falls in a 20-day period. This was evident for 1 (#71) of 4 residents reviewed for falls.
- D Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on medical record review and interview, it was determined that the facility failed to ensure staff assessed and developed a care plan to address a resident's needs related to dialysis; and failed to ensure staff completed pre and post dialysis assessments. This was found to be evident for 1 (Resident #136) out of 1 resident reviewed for dialysis.
- D Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that alternatives to side rails were attempted prior to the initation of side rails. This was found to be evident for 3 (Resident #46, #27 and #7) out 3 residents reviewed for side rails.
- D Observe each nurse aide's job performance and give regular training.
Inspectors wroteBased on review of employee files and interviews, it was determined that the facility failed to ensure that performance reviews were completed for nurse aides at least once every 12 months. This was found to be evident for 3 (Staff #30, #31 and #33) out of 3 nursing assistants reviewed for annual evaluation.
- D Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Inspectors wroteBased on review of employee files and interview, it was determined that the facility failed to ensure that staff received training related to caring for residents with behavioral health care needs. This was found to be evident for 3 (Staff #30, #31 and #18 ) out of 3 staff reviewed for training related to behavioral health.
- D Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to ensure that prescribed medications had adequate parameters in place to indicate when to administer as needed medications for pain; and failed to ensure documentation of the indication for use of an as needed narcotic pain medication. This was evident for 1 (Resident #3) of 4 residents reviewed for hospitalization and 1(Resident #7) out of 6 residents selected for unnecessary medication review .
- D Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Inspectors wroteBased on medical record review, it was determined that the facility failed to ensure that an as needed psychotropic medication order was limited to 14 days. This was found to be evident for one (#8) out of three residents reveiwed for unnecessary medications.
- D Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and interview, it was determined that the facility failed to develop and implement infection control policies and procedures to ensure that laundry was processed in a way that prevents cross contamination and that, once placed on a linen cart the clean laundry remained covered and was not used to store personal items within the linens on the cart. This was evident for 1 of 1 laundry room and 1 of 4 linen closets on the nursing units.
- D Develop and implement policies and procedures for flu and pneumonia vaccinations.
Inspectors wroteBased on record review, review of policy, and staff interview, it was determined that the facility failed to have a process in place to ensure that the flu vaccine and pneumonia vaccine was offered to each resident and that the residents/resident representatives received education regarding the vaccines. This was evident for 3 (#46, #21, and #48) of 5 residents reviewed for flu vaccinations and 4 (#46, #58, and #21) of 5 residents reviewed for the pneumonia vaccinations.
- D Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Inspectors wroteBased on record review, policy review, and staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure that their, 1) residents were offered the COVID 19 vaccination, resident and/or resident representatives were educated and that the education was documented in the resident's medical record and 2) staff were offered the COVID 19 vaccination, educated and that they maintained records of the education provided. This was evident for 5 (#46, #10, #58, #21, and #48) of 5 residents and 12 (#52, #5, #53, #54, #55, #19, #50, #57, #58, #22, #18, and #12) of 12 staff reviewed for COVID 19 vaccinations.
- D Ensure staff are vaccinated for COVID-19
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to develop and implement policies and procedures to ensure that 100% of staff were fully vaccinated, had an approved exemption, or had a temporary delay to receive the vaccination and/or was not eligible for the required second dose. This was evidenced by a 93% vaccination rate with 8 (#5, #54, #55, #19, #50, #57, #58, and #18) of 109 staff had not been fully vaccinated, received an approved exemption, or had a temporary delay.
- C Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Inspectors wroteBased on review of the facility assessment and interview, it was determined that the facility failed to ensure that the faciltiy assesment addressed the staff competencies that are necessary to provide the level and types of care needed for the resident population. This has the potential to affect all of the residents.
Fire safety inspections
27 fire safety citations on file: 12 on March 27, 2026, 6 on January 17, 2025, 9 on March 22, 2023.
Every fire safety citation27 citations
- F Have approved installation, maintenance and testing program for fire alarm systems.
- F Inspect, test, and maintain automatic sprinkler systems.
- F Have simulated fire drills held at unexpected times.
- F Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
- F Have generator or other power source capable of supplying service within 10 seconds.
- E Keep aisles, corridors, and exits free of obstruction in case of emergency.
- E Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- E Have properly located and lighted "Exit" signs.
- E Properly select, install, inspect, or maintain portable fire extinguishes.
- E Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
- E Install corridor and hallway doors that block smoke.
- E Meet other general requirements that are deficient.
- F Conduct testing and exercise requirements.
- F Have exits that are accessible at all times.
- F Inspect, test, and maintain automatic sprinkler systems.
- F To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- F Have generator or other power source capable of supplying service within 10 seconds.
- F Have proper medical gas storage and administration areas.
- D Develop and maintain an Emergency Preparedness Program (EP).
- D Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
- D Provide properly protected cooking facilities.
- D Have approved installation, maintenance and testing program for fire alarm systems.
- D Properly provide smoke detection systems in areas open to corridors.
- D Install corridor and hallway doors that block smoke.
- D To conduct inspection, testing and maintenance of fire doors by qualified individuals.
- D Have generator or other power source capable of supplying service within 10 seconds.
- D Ensure that testing and maintenance of electrical equipment is performed.
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.
| Measure | This home | Maryland | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.41 | 3.87 | 3.86 |
| Registered nurses | 0.76 | 0.84 | 0.69 |
| All nursing staff on weekends | 3.16 | 3.47 | 3.42 |
| Nurse aides | 1.89 | ||
| Licensed practical nurses | 0.76 | ||
| Nursing staff turnover (share who left in a year) | 38.5% | 40.2% | 45.8% |
| Registered nurse turnover | 8.3% | 38.7% | 42.9% |
| Administrators who left | 1 |
CMS expects 3.69 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 3.51 on weekdays and 3.16 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 31.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.39 in April to June 2025 to 3.41 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 | 3.41 | 0.76 | 3.51 | 3.16 | 31.5% | 0 of 90 | 80 |
| Oct to Dec 2025 | 3.54 | 0.82 | 3.68 | 3.19 | 28.2% | 0 of 92 | 79 |
| Jul to Sep 2025 | 3.38 | 0.85 | 3.52 | 3.02 | 30.4% | 0 of 92 | 82 |
| Apr to Jun 2025 | 3.39 | 0.81 | 3.54 | 3.02 | 12.0% | 0 of 91 | 70 |
| 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.
Quality measures
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 | 33.5 | 20.4 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 3.1 | 0.5 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 1.6 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.9 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.2 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 36.4 | 22.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 4.7 | 5.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 19.5 | 13.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 20.6 | 21.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 10.4 | 9.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.1 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.5 | 1.2 | 1.8 |
Owners and operators
Legal business name: Legal Business Name Not Available.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Ownership data not available |
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.
- How do you prevent falls and pressure injuries, and how are families told when one happens?Inspectors cited 20 problems in this area, most recently on July 6, 2026: "Ensure each resident must receive and the facility must provide necessary behavioral health care and services."
- How do residents and families raise a complaint or grievance, and how fast is it answered?Inspectors cited 18 problems in this area, most recently on March 27, 2026: "Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely."
- When is the care plan meeting, and can family attend it?Inspectors cited 16 problems in this area, most recently on March 27, 2026: "Ensure each resident receives an accurate assessment."
- How are medications reviewed, and how often are antipsychotic or sedating drugs used?Inspectors cited 11 problems in this area, most recently on July 6, 2026: "Ensure each resident’s drug regimen must be free from unnecessary drugs."
- Who is on the floor on Saturday and Sunday, and how many residents does each aide care for?Weekend nurse staffing here was 3.16 hours per resident per day, below the Maryland average of 3.47.
- How long has the current administrator been here?CMS counts 1 administrator who left in the period it measured.
Other nursing homes nearby
- Devlin Manor Nursing and Rehabilitation Center Cumberland, 0.8 mi · 3 of 5 stars · 25 citations
- Allegany Health Nursing and Rehab Cumberland, 2 mi · 4 of 5 stars · 23 citations
- Cumberland Healthcare Center Cumberland, 2.9 mi · 2 of 5 stars · 59 citations
- Frostburg Rehab Center Frostburg, 5.9 mi · 1 of 5 stars · 51 citations
- Mountain City Rehab Center Frostburg, 7 mi · 1 of 5 stars · 65 citations
- Complete Care at Dawnview LLC Fort Ashby, 10 mi · 4 of 5 stars · 35 citations
- Egle Nursing Home Lonaconing, 11.6 mi · 1 of 5 stars · 42 citations
- Casselman Healthcare and Rehabilitation Center Meyersdale, 16.2 mi · 2 of 5 stars · 40 citations
Maryland contacts for a concern about a nursing home
These are the official offices in Maryland. NursingHomeClear cannot take or act on complaints.
- Inspections and complaints: Maryland Department of Health, Office of Health Care Quality, the state agency that inspects nursing homes for CMS and takes complaints about care.
- Resident advocate: Maryland Long-Term Care Ombudsman Program, Maryland Department of Aging, 800-243-3425. The long-term care ombudsman is a free, confidential advocate for residents and families, set up under the federal Older Americans Act.
- State inspection reports: Maryland Health Care Commission, Maryland Quality Reporting, Nursing Homes, where Maryland publishes its own records on licensed homes.
Common questions
- What is Lions Rehab Center's Medicare star rating?
- CMS rates Lions Rehab Center 2 out of 5 stars overall, with 2 for health inspections, 4 for staffing and 2 for quality measures (CMS data as of September 1, 2026).
- How many deficiencies did Lions Rehab Center get at its last inspection?
- 18 health deficiencies at the standard inspection on March 27, 2026. The Maryland average is 17.
- Has Lions Rehab Center been fined?
- CMS lists no fines in the last three years.
- Does Lions Rehab Center 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 Lions Rehab Center?
- CMS lists 1 owner or manager. Legal business name: Legal Business Name Not Available.
Sources
- Ratings, staffing and fines: CMS Provider Information, released September 30, 2026, data as of September 1, 2026.
- Citations: CMS Health Deficiencies and Fire Safety Deficiencies.
- Owners: CMS Ownership. Penalties: CMS Penalties.
- Staffing by quarter: CMS Payroll Based Journal Daily Nurse Staffing, April 2025 to March 2026, summed by NursingHomeClear.
- Inspector summaries: CMS Full Statement of Deficiencies (CMS-2567 text), data as of September 1, 2026. Each quote is the part of the statement before the detailed findings.
- Inspection reports with the inspectors' full notes are on this home's Medicare.gov page.
- Something wrong on this page? Ask for a correction. We fix errors in our copy of the data; findings themselves can only be changed by CMS and the state.
- NursingHomeClear is independent and not affiliated with CMS, Medicare or any state agency. This page reports federal records; it does not rate, recommend or endorse any home, and it is not medical or legal advice.