Home / Maryland / Middle River
1300 Windlass Drive, Middle River, MD 21220 · Baltimore County · (410) 687-1383
130 certified beds, about 119 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1988
CMS Care Compare ratings, data as of September 1, 2026 · CCN 215181 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on March 3, 2026, inspectors cited 32 health deficiencies (the Maryland average is 17, the national average 9.2).
Of 88 health citations since October 2019, 2 were rated as actual harm or immediate jeopardy to residents.
CMS lists 1 fine totaling $13,270 in the last three years; the largest was $13,270, and the latest is dated October 21, 2024.
Nurses and nurse aides worked 3.40 hours per resident per day, against 3.87 across Maryland and 3.86 nationally. Registered nurses accounted for 0.45 of those hours.
CMS links it to Hill Valley Healthcare, an affiliated group of 43 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 88 health citations on file.
Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to ensure residents were offered the opportunity to formulate Advanced Directives. This was found to be evident for 6 (#1, #2, #90, #11, #7, & #8) out of 7 residents reviewed for Advanced Directives planning during the recertification survey.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure notice of resident transfers and discharges were submitted to the representative of the Office of the State Long Term Care Ombudsman. This deficient practice was identified during annual survey and had the potential to affect all residents who experienced a transfer or discharge.
Inspectors wroteBased on interviews, observations, and record reviews, it was determined the facility failed to ensure a residents right to self-determination by honoring the resident's preference regarding the timing of blood sugar monitoring. This deficient practice was evident for one (#4) resident reviewed for self-determination during the annual survey.
Inspectors wroteBased on observations and staff interviews, it was determined that the facility staff failed to provide services necessary to maintain a sanitary environment. This was observed on 1 (room [ROOM NUMBER]'s) bathroom during the initial tour.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure a resident's PRN (as needed) psychotropic (mental health) medication order was no longer than 14 days without a provider's rationale. This was evident for 1 (Resident #10) of 5 residents reviewed for unnecessary medication.
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 (#13) out of 8 residents reviewed for care planning during the recertification survey.
Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure residents received quarterly care plan meetings. This was evident for 4 (Resident #7, #8, #16, and #129) of 4 residents reviewed for care planning.
Inspectors wroteBased on record reviews, interviews, and observations, it was determined that the facility staff failed to ensure services were provided in accordance with professional standard of practice when staff failed to administer medications according to physician orders. This deficient practice was evident for two (#129, #49) of two residents review for medication administration during the annual.
Inspectors wroteBased on interviews and record reviews, it was determined that the facility staff failed to ensure residents received services to maintain or improve the ability to perform Activity of Daily Living (ADL). This deficient practice was evident for one (#4) resident reviewed for assistive devices during the annual survey.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to provide necessary services to maintain good personal hygiene for dependent Residents. This was found evident in 2 (Resident #63, #9) out of 5 residents reviewed for Activity of Daily Living (ADL) cares.
Inspectors wroteBased on record review and interviews it was determined that the facility failed to identify and provide appropriate interventions and notifications for a resident's condition. This was found evident of 2 (Resident #63 & 4) out of 2 residents reviewed for insulin during the survey.
Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to ensure services were provided to address a resident's hearing needs. This deficient practice was evident for one Resident (#48) reviewed for hearing services during the annual survey.
Inspectors wroteBased on observation, medical record review and interviews, it was determined the facility staff failed to clarify appropriate care measures to prevent complications from a hand contracture. This was evident for 1 (resident #74) of 1 resident reviewed for mobility.
Inspectors wroteBased on observations, interviews, review of facility's policy and record review, it was determined that the facility failed to provide appropriate treatments to prevent complications for a resident who required enteral nutrition. This was evident for 1 (Resident #12) out of 1 resident reviewed for tube feeding during the survey.
Inspectors wroteBased on observations and interviews with staff, it was determined the facility failed to 1) have a designated nurse supervisor/charge nurse and 2) have sufficient staff dispense medications in a timely manner. This was found to be evident during one early hour observation and during an observation of medication administration.
Inspectors wroteBased on observation and interview with facility staff, it was determined that the facility failed to post all of the required staffing information on a daily basis. This was evident on 1 out of 6 days on the survey.
Inspectors wroteBased on observations, record reviews, and interviews, it was determined that the facility failed to administer medications according to procedures that ensure accurate dispensing. This was evident for 1(Resident #82) out of 4 residents reviewed for medication administration.
Inspectors wroteBased on review of the clinical record and staff interview, it was determined that the facility staff failed to adequately monitor a resident's drug regimen which allowed an unnecessary duplicate order for medication. This finding was evident for 1 (Resident #49) of 6 residents reviewed for unnecessary medications during the survey.
Inspectors wroteBased on observations, review of facility's policy and interviews with staff, it was determined that the facility failed to properly store a Resident's medication. This was found evident on 1 random observation during the survey.
Inspectors wroteBased on interview and medical record review, it was determined that the facility failed to ensure that residents who require dental services on a routine or emergent basis receive necessary or recommended dental services in a timely manner. This was evident for 2 (Resident #74 and #90) of 2 residents reviewed for dental services during the survey.
Inspectors wroteBased on observation, record review, and interviews, it was determined that the facility failed to ensure that residents were served a meals according to a predetermined menu and their preferences. This was found to be evident for 3 (#3, #5, and #90) out of 8 resident's meals that were observed for correctness during the recertification survey.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to serve food at residents preferred temperature. This was found to be evident for 2 (#90, #91) out 8 residents interviewed for palatable food during the recertification survey.
Inspectors wroteBased on observation and record review, it was determined that the facility failed to provide assistive devices for meals to a resident. This was found to be evident for 1 (#14) out of 2 residents reviewed for assistive devices during the recertification survey.
Inspectors wroteBased on observations, interviews, and record reviews, it was determined that the facility failed to ensure sanitary and safe food handling practices were followed to reduce the risk of foodborne illness. This was found to be evident in the refrigerators, freezer and storage areas observed during the recertification survey.
Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that a resident's medical record document was accurately completed. This was evident for 1 (Resident #10) of 2 residents reviewed for Preadmission Screening and Resident Review (PASARR).
Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure linens were stored to maintain infection prevention. This was evident for 4 of 4 hallways observed during the annual survey.
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to keep equipment in the kitchen in safe, operating condition. This was found to be evident for the walk-in freezer, plate warmer, and the hot water heater during the kitchen tours.
Inspectors wroteBased on observations and interviews it was determined the facility failed to ensure that the resident's call system was functioning properly. This was found to be evident for 1 of 3 units observed during the survey.
Inspectors wroteBased on administrative record review and staff interview, it was determined that the facility failed to ensure staff received training on abuse, neglect, and exploitation. This deficient practice was evident for 2 of 6 employee files reviewed during the annual survey.
Inspectors wroteBased on administrative record review and staff interviews, it was determined that the facility failed to ensure staff received training on Quality Assurance and Performance Improvement (QAPI). This deficient practice was evident for 3 of 6 employee files reviewed during the annual survey.
Inspectors wroteBased on administrative record review and staff interview, it was determined that the facility failed to ensure staff received infection control training. This deficient practice was evident for 3 of 6 employee files reviewed during the annual survey.
Inspectors wroteBased on administrative record review and staff interview, it was determined that the facility failed to ensure staff received compliance & ethics training. This deficient practice was evident for 3 of 6 employee files reviewed during the annual survey.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#3, #6, #7, #8) of 4 residents reviewed for falls during a complaint survey.
Inspectors wroteBased on observation of Resident # 1 room [ROOM NUMBER] B, the facility failed to clean the room, sweep and mop the floor. This was evident for 1 out of 1 resident and room.
Inspectors wroteBased on medical record review and interview, the facility staff failed to provide treatment/services as ordered to prevent/heal pressures ulcers (Resident #5). This is evident for 1 of 3 residents reviewed for pressure ulcers during a complaint survey.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to implement the Dietitian's recommendations for residents with weight loss (Resident #5 and #10) and failed to follow up on a physician's report for a resident evaluated for weight loss (Resident #5). This was evident for 2 of 3 residents reviewed for weight loss during a complaint survey.
Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to obtain a diagnostic test as ordered for a resident (Resident #5). This was evident for 1 of 11 residents reviewed during a complaint survey.
Inspectors wroteBased on observation and staff interview, it was determined the facility failed to post a notice of where the results of the most recent surveys, certifications, and complaint investigations were located. This was evident during the first day of the complaint survey.
Inspectors wroteBased on investigation of intakes #314675 and #314688, review of facility documents, and interviews it was determined the facility failed to maintain an effective Grievance system. This was evident for 5 of 6 months of Grievance forms from the months of April through September of 2025 reviewed during the complaint survey.
Inspectors wroteBased on complaint intakes, observations, and staff interviews, it was determined that the facility failed to provide quality of care services to their residents by not having clean towels or wash clothes used for washing up. This was evident for 3 (#314683, #314678 and #314685) of 5 complaint intakes reviewed during a complaint survey.
Inspectors wroteBased on investigation of Intake #314680, observation, and interviews with facility staff it was determined the facility failed to provide an environment that promotes resident respect and dignity. This was evident for 1 (Resident #117) of 1 resident reviewed for dignity during the complaint survey.
Inspectors wroteBased on medical record review, and interviews it was determined that the facility failed to honor a resident's preference to receive a shower instead of a bed bath. This was evident for 1 (Resident #116) of 1 resident reviewed for preferences during the complaint survey. On 10/06/2025 at 9:40 AM, during an interview with Resident #116 stated, he/she has not had a shower in over 2 years, his/her preference is a shower, but has only received bed baths. Resident #116 continued to state, the shower room on the unit he/she resides on has not been in use and is used to store wheelchairs. On 10/06/2025 at 12:30 PM, during a review of Resident #116's medical record revealed the following: A Physician order dated 2/20/2023 weekly shower schedule on Wednesday and Saturdays on 7-3 shift. [...]
Inspectors wroteBased on observation during tours of the facility and investigations into intakes #314685 and #314689, it was determined that the facility staff failed to ensure the facility was free from odors. This was evident for 2 out of the 4 nursing units observed during the complaint survey.
Inspectors wroteBased on clinical record review, investigation of facility reports, and interviews, it was determined that the facility failed to conduct a thorough investigation of 1) and allegation of abuse and 2) an accident with a serious injury. This was evident for 2 (Residents #106, #114) of 25 residents reviewed during the complaint survey.
Inspectors wroteBased on complaint #2596795, record reviews, and interviews, it was determined that the facility failed to develop an impaired mobility care plan as required. This deficiency was observed in 1 (Resident #108) of 4 care plans reviewed for mobility needs during the complaint survey.
Inspectors wroteBased on investigation of intakes, record review, observation, and interview, it was determined that the facility failed to 1) provide incontinence care timely, 2) provide showers for dependent residents, and 3) provide incontinence care in a professional manner. This as evidence for 4 residents (Residents #119, #105, #121, #112) out of 25 residents reviewed during the complaint survey.
Inspectors wroteBased on clinical record review and an investigation of intake #314682 it was determined that the facility staff failed to conduct a thorough investigation into an accident thereby denying facility staff the ability to adequately evaluate possible cause(s) to this and future accidents. This was evident for 1 (Resident #113) out of 1 resident reviewed for accidents during the complaint survey.
Inspectors wroteBased on observation of a test tray and information provided from intakes, it was determined that the facility staff failed to ensure food was served in a palatable manner. This was evident for 1 out of 2 test trays sampled.
Inspectors wroteBased on investigation of intake #314675, observation, and interview it was determined the facility failed to properly verify pertinent information prior to meal service. This was evident for 1 (Resident #118) of 1 reviewed for meal service during the complaint survey.
Inspectors wroteBased on clinical record review, investigation of intake #314679, staff interview, and interview with complainant, it was determined that the facility staff failed to ensure medical records were complete with all communication flow sheets with the dialysis center. This was evident for 1 (Resident #114) resident out of 25 residents that were part of the survey sample.
Inspectors wroteBased on resident interview, staff interview, clinical record review, and a review of the facility investigation of intake #MD00207612, it was determined that the facility staff failed to ensure residents were free from abuse. This was evident for 1 (#97) out of 6 residents reviewed for abuse. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Actual Harm Past Non-compliance (PNC).
Inspectors wroteBased on observation and facility staff interview, it was determined that the facility failed to have a safe/clean/comfortable/homelike environment. This was found to be evident in 6 out of 8 Resident rooms observed by the surveyors during the tours of the facility.
Inspectors wroteBased on staff interviews and medical record review it was determined that the facility failed to provide notification to the Ombudsman of Residents that transferred to the hospital and discharged from the facility. This was found to be evident in 9 out of 9 Residents (#4, #8, #24, #32, #33, #41, #60, #105 and #118) reviewed for hospitalizations.
Inspectors wroteBased on observation, staff interview and clinical record review, it was determined that the facility staff failed to ensure that MDS (Minimum Data Set) assessments were coded accurately for Residents. This was found to be evident for 5 Residents (#41, #77, #119, #133 and #118) out of 5 Residents reviewed for accuracy of MDS assessments.
Inspectors wroteBased on staff interview, clinical record review, and an investigation into Intake #MD00205003, it was determined that the facility staff failed to ensure residents right to determine who speaks for them is respected. This was evident for 1 (#128) out 44 residents in the survey sample.
Inspectors wroteBased on record review, review of complaint intake MD 00209581 and staff interview, it was determined that the facility failed to implement the grievance process as evidenced by the failure to initiate grievances and to resolve complaints. Additionally, the facility staff failed to ensure the residents' right to voice grievances with respect to care/ treatments and the concerns of staffs' behaviors regarding their facility stay. This was evident for 1 (Resident# 144) out of 20 residents reviewed for facility complaint reviews during an annual survey.
Inspectors wroteBased on medical record review, and staff interview, it was determined the facility staff failed to review and revise the interdisciplinary care plans to reveal accurate interventions to meet the needs of the residents. This was evident for 2 (Residents #32 and #91) of 44 residents selected for investigation during the survey process.
Inspectors wroteBased on observation, interview and medical record review it was determined that the facility failed to provide respiratory care and services appropriately. This was found to be evident for 2 Residents (#8 and # 57) out of 3 residents that were reviewed for respiratory care and services.
Inspectors wroteBased on observations, interviews and medical record review it was determined that the facility failed to store medications appropriately. This was found to be evident in 1 (Resident #8) out of 1 resident for medication storage.
Inspectors wroteBased on observation and staff interview it was determined that the facility staff failed to ensure food products were properly labeled and disposed of when they are past their expiration dates. This was observed on two tours of the kitchen.
Inspectors wroteBased on clinical record review and staff interview it was determined that the facility staff failed to ensure clinical records were maintained in an accurate manner. This was evident for 1 (#4) out of 44 residents in the survey sample.
Inspectors wroteBased on observations, and interviews, it was determined that the facility failed to provide a safe, sanitary environment to prevent the development and transmission of disease and infection. This was evidenced by: 1) Staff failing to perform hand hygiene before entering the room of a resident with enhanced barrier precautions 2) Failure to keep contaminated pillows separate and away from clean pillows in the laundry room
Inspectors wroteBased on observations, and interviews, it was determined that the facility failed to keep a sanitary environment. This was found evident on 1 of 3 floors observed in the laundry room area.
Inspectors wroteBased on record review and staff interview it was determined that the facility failed to keep a resident safe by mishandling an oxygen tank which resulted in harm. This was evident for 1 (#318) of 5 residents reviewed for accidents.
Inspectors wroteBased on review of Geriatric Nursing Assistant (GNA) personnel files and staff interview, it was determined the facility failed to conduct yearly performance reviews at least every 12 months for 4 out of 5 personnel files reviewed.
Inspectors wroteBased on record review and staff interview it was determined that the facility staff failed to put a system in place to ensure proper infection surveillance policies and procedures were in place by; 1) reading Tuberculosis Skin Test (TST) results outside of the specified time frame and 2) failed to update Infection Prevention and Control Program Policy (IPCP) annually. This was true for 3 (#95, #368, #427) of 3 residents reviewed for infection control and for 2 of 3 policy's reviewed for infection control. These deficient practices have the potential to affect all residents, visitors and staff in the facility.
Inspectors wroteBased on surveyor observation and staff interview, it was determined the facility staff failed to provide housekeeping and maintenance services necessary to keep the building clean, neat, attractive and in good repair including the grounds. This was evident throughout the survey 1) the outside grounds; 2) on 3(200, 300, and 500) of 4 hallways; and 3) in 4 (506, 509, 505, 502) of 6 resident rooms.
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 5 (#74, #105, #19, #70, #69) of 8 residents reviewed for hospitalization.
Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to document what preparation and orientation was given to residents to ensure an orderly transfer to an acute care facility. This was evident for 8 (#69, #111, #83, #119, #74, #105, #19, and #70 ) of 8 residents reviewed for hospitalization.
Inspectors wroteBased on medical record review and staff interview it was determined the facility staff failed to give the written bed hold policy to the resident or resident representative upon transfer/discharge of a resident to an acute care facility. This was evident for 4 (#74, #105, #19, #70) of 8 residents reviewed for hospitalization.
Inspectors wroteBased on medical record review and staff interview, it was determined the facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded. This was evident for 4 (#118, #105, #19, and #77) of 34 resident investigations during the survey.
Inspectors wroteBased on resident representative and resident interview, observation, medical record review and staff interview it was determined that the facility failed to develop and implement comprehensive person-centered care plans. This was evident for 1 (#105) of 1 residents reviewed for urinary tract infections and 1 (#72) of 6 residents reviewed for accidents.
Inspectors wroteBased on medical record review and staff interview, it was determined that the facility failed to maintain complete and accurate medical records by: 1) failing to void MOLST (Maryland Medical Order for Life Sustaining Treatment) forms when a new MOLST has been created, 2) failing to ensure a resident's Preadmission Screening and Resident Review (PASRR) Level I ID Screen for Mental Illness and Intellectual Disability or related conditions were retained in the resident's medical record, 3) failing to accurately document a resident's refusal to wear a soft helmet, 4) allowing the Social Service Director to sign notes in the electronic medical records as a LCSW (licensed clinical social worker) in the absence of having a social work license, and 5) failing to ensure the in-house nurse practitioner's notes were available on the medical record for review and failed to ensure the [...]
Inspectors wroteBased on interview and record review, it was determined that the facility staff failed to, in the presence of a resident - to - resident altercation, provide immediate intervention to ensure the safety and wellbeing of the resident. This was evident for 1 (#39) of 7 residents reviewed for abuse.
Inspectors wroteBased on interview and record review it was determined that the facility failed to report allegation of abuse to the Office of Health Care Quality. This was evident for 1 (#39) of 7 Residents reviewed for abuse.
Inspectors wroteBased on record review and interview it was determined that the facility failed to initiate an investigation of an alleged violation of abuse was reported to staff. This was evident for 1 (#39) of 7 residents reviewed for abuse.
Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to complete a Minimum Data Set (MDS) assessment within 14 days of the Assessment reference date (ARD). This was identified for 1 (#7) of 2 residents reviewed for pressure ulcers. The MDS is part of the Resident Assessment Instrument that was Federally mandated in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.
Inspectors wroteBased on review of the medical records, and resident and staff interviews it was determined the facility failed to perform appropriate revisions to the care plan interventions as resident care needs became apparent or changed over time as evidenced by failure to update interventions on an incontinence plan of care. This was evident for 1 (#69) of 2 residents reviewed for sensory (vision) concerns. 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.
Inspectors wroteBased on review of a complaint, medical record, observation, and interview it was determined that the facility failed to provide care and treatment in accordance with professional standards as evidenced by: 1)failure to ensure medications were ordered and administered as indicated; 2) failure to complete a thorough physical assessment after a fall 3) failure to provide activity of daily living (ADL) care as needed 4) failed to render care in accordance with the resident's care plan and failed to apply prescribed/ ordered treatments. This was found to be evident for 1 (#39) of 3 residents reviewed for 5 day hospice respite admissions, and for 1 (#7) of 2 residents reviewed for pressure ulcers.
Inspectors wroteBased on observation, record review, and staff interview it was determined that the facility failed to follow a physician's order for oxygen administration for a resident. This was evident for 1 (#39) of 2 residents reviewed for respiratory care.
Inspectors wroteBased on medical record review and staff interview it was determined a physician and a certified registered nurse practitioner (CRNP) failed to write, sign and date medical visit progress notes in resident medical records the day the resident was seen. This was evident for 2 (#83, #119) of 8 residents reviewed for hospitalization.
Inspectors wroteBased on medical record review and staff interview it was determined that the facility failed to assure that residents are seen by a physician at least every 30 days for the first 90 days after a resident's admission. This was evident for 1 (#83) of 8 residents reviewed for hospitalization.
Inspectors wroteBased on medical record review it was determined that the facility failed to ensure the pharmacist identified medication order irregularities during the monthly pharmacy review. This was found to be evident for one out of three (Resident #319) resident's reviewed for 5 day hospice respite admission.
Inspectors wrote2) On 10/28/19 at 11:34 AM, review of Resident #19's October 2019 MAR (medication administration record) revealed had 2 orders for narcotic medication to be given by mouth as needed for pain with no clear indication as to which medication to give first. The resident had an order Oxycodone (narcotic) 0.5 MG (milligram) tablet give 0.5 tablet every 4 hours as needed for pain and an order for Morphine Sulfate (concentrate) Solution 20 MG/ML (milliliter) give 0.5 MG by mouth every 6 hours as needed for pain/resp. Also, the morphine order should have been clarified with the physician as the morphine dose of 0.5 MG (0.025 ML) was not a recommended adult dose per the FDA (Federal Drug Administration) and the dose, 0.025 ML (0.5 MG), would not be accurately measurable in its current form. [...]
Inspectors wroteBased on observation, medical record review and interview it was determined that the facility failed to ensure a medication error rate of less than 5% as evidenced by 2 errors observed during the medication observation of 32 opportunities for errors resulting in a medication error rate of 6.25. This was found to be evident for two (Resident #425 and #426) out of four residents observed during the medication administration observation.
Inspectors wroteBased on review of medical record and interview it was determined that the facility failed to ensure that narcotic medication that was removed from the resident's supply was administered to the resident. This was found to be evident for one (Resident #319) out of 3 residents reviewed for 5 day hospice respite admission.
Inspectors wroteBased on resident interviews and observations of the kitchen with the testing of a food tray it was determined that the facility failed to serve food at a preferable temperature. This was identified on the unit that is the last to be served food.
Inspectors wroteBased on observations and staff interview it was determined that the facility failed to have an effective system in place to ensure that the posting of staff is up to date and current. The facility is required to list the total number of staff and the actual hours worked by the staff to meet this regulatory requirement. The information should reflect staff absences on any shift due to callouts and illness. The current and accurate staffing data should be available to residents and visitors at any given time.
22 fire safety citations on file: 9 on March 3, 2026, 11 on October 21, 2024, 2 on October 28, 2019.
| Date | Penalty | Amount or length |
|---|---|---|
| October 21, 2024 | Fine | $13,270 |
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) | 3.40 | 3.87 | 3.86 |
| Registered nurses | 0.45 | 0.84 | 0.69 |
| All nursing staff on weekends | 3.16 | 3.47 | 3.42 |
| Nurse aides | 1.95 | ||
| Licensed practical nurses | 0.99 | ||
| Nursing staff turnover (share who left in a year) | not reported | 40.2% | 45.8% |
| Registered nurse turnover | not reported | 38.7% | 42.9% |
| Administrators who left | 1 |
CMS expects 4.11 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 3.49 on weekdays and 3.16 on weekends, 9% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 10.5% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 4.02 in April to June 2025 to 3.40 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 | 3.40 | 0.45 | 3.49 | 3.16 | 10.5% | 0 of 90 | 119 |
| Oct to Dec 2025 | 3.51 | 0.51 | 3.62 | 3.23 | 10.3% | 0 of 92 | 114 |
| Jul to Sep 2025 | 3.49 | 0.54 | 3.62 | 3.14 | 6.7% | 0 of 92 | 115 |
| Apr to Jun 2025 | 4.02 | 0.57 | 4.31 | 3.31 | 18.3% | 0 of 91 | 116 |
| 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. If you work here, your report helps start one.
| 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 | 8.7 | 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 | 0.3 | 1.5 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 4.5 | 2.4 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 1.3 | 1.1 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 5.5 | 22.2 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 5.4 | 5.9 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 19.0 | 13.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 22.3 | 21.0 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 9.3 | 9.8 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.3 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.4 | 1.2 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Oakwood SNF LLC's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (50.8% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
50.8% this home
No different from the national rate
US median of homes 51.5% · Maryland: 90 better, 29 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 217 eligible stays.
11.4% this home
No different from the national rate
US median of homes 10.7% · Maryland: 0 better, 41 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 255 eligible stays.
7.8% this home
No different from the national rate
US median of homes 7.1% · Maryland: 5 better, 6 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 149 eligible stays.
64.0% 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. 100 residents counted.
1.2% 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. 168 residents counted.
1.4% this home
Median of homes: Maryland2.4% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 168 residents counted.
96.0% 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. 25 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: OAKWOOD SNF LLC. CMS links this home to Hill Valley Healthcare, a group of 43 nursing homes averaging 1.7 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Oakwood Holdco LLC | 5% or greater direct ownership interest | Organization | 100% | 06/01/2021 |
| Copper Mddc Trust | 5% or greater indirect ownership interest | Organization | 06/01/2021 | |
| Gold Mddc Trust | 5% or greater indirect ownership interest | Organization | 06/01/2021 | |
| Hill Valley Healthcare LLC | 5% or greater indirect ownership interest | Organization | 06/01/2021 | |
| Mddc Noble Parentco LLC | 5% or greater indirect ownership interest | Organization | 06/01/2021 | |
| Silver Mddc Trust | 5% or greater indirect ownership interest | Organization | 06/01/2021 | |
| Meisner, Robert | 5% or greater indirect ownership interest | Individual | 06/01/2021 | |
| Preis, Meir | W-2 managing employee | Individual | 06/01/2021 | |
| Schwartz, Steven | W-2 managing employee | Individual | 06/01/2021 | |
| Buckley, Erik | Corporate officer | Individual | 06/01/2021 |
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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