Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 43 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
1J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
34D
5E
1F
Potential for minimal harm
0A
0B
0C
February 26, 2026Standard inspection · 7 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 observation and staff interview, it was determined that the facility failed to ensure that refrigerated food items were consistently labeled and dated with preparation and expiration dates to maintain sanitary storage conditions and prevent the potential for serving unsafe food. This deficient practice was identified during the initial and follow-up tours of the kitchen during the recertification survey.
- E
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to provide respiratory care services for residents that meets professional standards. This was evident for 6 residents (Resident #161, #121, #162,#118, #160, and #2 ) out 9 reviewed for respiratory services during the annual survey. The findings Include:1) On 02/19/2026 at 9:29 AM, during the initial tour of the facility, Resident #161 was observed lying in bed receiving oxygen via nasal cannula. The oxygen concentrator was set at 4.5 liters per minute (LPM). On 02/19/2026 at 11:30 AM, review of the resident's electronic health record (EHR) revealed no active physician order for oxygen therapy or oxygen flow rate. An order dated 02/18/2026 stated: Change, Date & Initial O2 tubing & Humidifier bottle weekly & PRN every night shift every Wed for Infection Prevention. [...]
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview, the facility failed to ensure that food was served to residents at an appropriate and palatable temperature to ensure quality and safety. This deficient practice was identified during test tray observation on 1 (second floor) out of 2 floors during the facility's recertification survey.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure that residents and/or their representatives were provided with written notice of hospital transfer and information regarding the facility's bed-hold policy. This was found evident for 2 (Residents #14 and #5) out of 2 residents reviewed for hospitalization during the facility's recertification survey.
- 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 observations, record reviews, and interviews it was determined that the facility failed to develop and/or update the comprehensive care plan to include oxygen therapy. This was evident for 1 (Resident #2) out of 5 residents observed for respiratory care during the annual survey. A care plan is a simple written plan that explains how to take care of a resident's health and daily needs. It lists what the resident needs help with, what their goals are, and what caregivers should do to help them. It makes sure everyone helping the resident knows the same plan so the care stays organized and consistent.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to accurately and completely document a resident's pain as ordered by the physician. This was evident for 1 (Resident #119) of 1 resident reviewed for pain management.
- D
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Inspectors wroteBased on observations, record reviews, and interviews with facility staff, it was determined that the facility failed to ensure residents were served meals according to the predetermined menu that incorporated resident preferences. This was evident for three residents (Residents #2, #63, and #163) out of four residents reviewed for concerns related to the food menu during the facility's recertification survey.
August 29, 2025Complaint inspection · 14 citations
- G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on medical record review and interview with staff and resident it was determined that the facility staff neglected his assigned patients and failed to provide care to them causing identified harm to a resident when the care was refused to be administered. This resulted in psychosocial harm to Resident #2 and was evident during the review of a facility reported incident reviewing documented neglected care of 13 (Residents #2, #29, #33, #39 #40 #30, # 31, #32, #34, #35, #36,# 37, and # 38 ) of 13 residents reviewed during the complaint survey.
- G
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on review of medical records and other pertinent documentation, observations, and interviews, it was determined that the facility failed to prevent avoidable falls. This was found to be evident for 1 (Resident #7) out of 2 residents reviewed for accidents during the survey. The fall resulted in actual harm to Resident #7.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on record review and interview, it was determined the facility staff failed to identify and provide needed care and services by 1) failing to respond timely when residents activated their call bells for assistance, and 2) failing to provide Gastrostomy Tube site care. This was evident for 1 (Resident #5) of 17 residents reviewed for Quality of Care during the complaint 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 record review and interview it was determined the facility staff 1) failed to determine on admission if a resident had an advance directive and provide information about the right to formulate an advance directive; and 2) failed to identify a primary decision-maker for a resident determined not to have decision-making capacity. This was evident for 1 (Resident #5) of 17 residents reviewed for Quality of Care and Treatment during the complaint 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 medical record and statement from Staff # 13, the facility failed to notify Responsible party after the Resident fell on 8/23/24. This was evident for 1 (Resident # 21) out of 1 resident reviewed during the complaint survey.
- D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Inspectors wroteBased on interviews with resident, staff and review of the grievance process it was determined that the facility failed to give adequate responses to grievances presented by a resident/family regarding an allegation of neglect. This was found evident in the review a facility reported incident of neglect that was also a reported grievance from Resident #2 reviewed during the complaint survey.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on record review and interviews it was determined the facility staff failed to report incidents within required timeframes. This was evident for 2 (#21 and #2) of 12 residents reviewed for neglect and 2 (#15 and #4) of 6 residents reviewed for abuse during the complaint survey.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review and interview with facility staff it was determined that the facility staff failed to thoroughly investigate allegations of abuse and neglect. This was evident for 2 (Residents #15 and #4) of 6 residents reviewed for abuse and for 1 (Resident #2) of 12 residents reviewed for neglect during the complaint survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on medical record review, observation and interview it was determined that the facility failed to complete accurate assessments of a resident related to the Brief interview of mental status (BIMS) assessment completed on the minimum data set (MDS). This was evident for 1 of 5 residents (Resident #2) reviewed during the complaint survey.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on medical record review and interview with facility staff it was determined that the facility failed to develop a comprehensive resident-centered care plan regarding the resident's pertinent diagnosis. This was evident for 1(Resident #5) of 17 residents reviewed for Quality of Care and for 1 (Resident #2) of 6 residents reviewed for Abuse during the complaint survey.
- D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on interview and record review, the facility failed to clean and change the brief of an incontinent resident. This was evident for 1 resident (Resident # 6) out of 5 residents reviewed during the complaint survey.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on medical record review and staff interviews it was determined the facility staff failed to ensure that Resident #25's personal hygiene needs were adequately met by offering and providing showers as scheduled. This was evident for 1 (Resident # 25) of 4 residents reviewed during the survey process.
- D
Provide enough food/fluids to maintain a resident's health.
Inspectors wroteBased on medical record review and interview, the facility failed to monitor a resident's hydration and nutrition status resulting in the resident's change in condition that led to the resident being transferred to the local hospital to be treated for dehydration. This was evident for 1 (Resident #17) of 3 residents reviewed for neglect during a complaint survey.
- D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on medical record review and interview it was determined the facility staff failed to maintain the medical record in the most complete and accurate form for a Resident. This was evident for 1 (Resident #7) of 2 residents selected for review during the survey process.
October 16, 2024Standard inspection, Complaint inspection · 20 citations
- J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, medical record review, review of the facility's investigation reports, and interviews with staff, it was determined that the facility failed to supervise and provide a secure environment for a resident residing in a secure unit. These failures contributed to the resident eloping and placed the resident at increased risk for serious harm. This was evident for 1 (Residents #374) of 3 residents reviewed for elopement. The Maryland Office of Health Care Quality (OHCQ) determined that this concern met the Federal definition of Immediate Jeopardy Past Non-compliance.
- 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, interviews and record reviews, it was determined that the facility failed to maintain clean carpets. This was found to be evident in many carpeted areas of the facility.
- E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on review of a facility reported incident and interview with staff, it was determined that the facility failed to report the results of an alleged abuse investigation within five working days to the Office of Health Care Quality. This was evident for 4 (Resident #375, #29, #72, and #223) out of 12 residents investigated for abuse during the annual and complaint survey.
- D
Give the resident's representative the ability to exercise the resident's rights.
Inspectors wroteBased on medical record review and interviews with facility staff, it was determined the facility failed to identify the responsible party (RP) and notify them of changes. This was evident for 3 (Resident #382, #66, and #101) out of 57 residents reviewed for resident rights during the facility's annual and complaint survey.
- D
Ensure that residents are fully informed and understand their health status, care and treatments.
Inspectors wroteBased on medical record review and interviews it was determined that the facility failed to inform in advance of treatment changes. This was found evident for 1 (Resident #382) out of 18 residents reviewed for rights during the complaint portion of the annual survey.
- D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Inspectors wroteBased on observation and interviews with facility staff, it was determined that the facility failed to provide the residents ' care with privacy and dignity when providing medications and administering care. This was found to be evident for 3 (Resident #111,114 and #143) out of 5 residents during medication administration.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on record review and interviews with the residents and staff, it was determined that the facility failed to answer call bells timely to attend to the needs of dependent residents. This was evident for 3 (Resident # 81, #106, and #382) out of 6 residents call history reports reviewed during the annual and complaint survey.
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on facility investigations, record reviews, interviews, and observations, the facility failed to protect residents from abuse and neglect. This was found to be evident for 2 (Resident #41 and #47) out of 12 residents investigated during for abuse and neglect during the annual and complaint survey.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on record review, review of facility investigation, and interviews it was determined that the facility failed to suspend a staff member and prevent potential abuse while an abuse investigation was still being conducted. This was found evident of 1 (Resident #385) out of 12 Residents reviewed for abuse.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on record review and interview with staff, it was determined that the facility failed to ensure the local Ombudsman was notified of a facility initiated resident discharge or transfer. This was evident for 1 (Resident #25) out of 3 residents investigated for hospitalizations during the annual survey.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, medical record review, and staff interview it was determined that the facility staff failed to code the resident's status accurately on the Minimum Data Set (MDS) assessment. This was found to be evident for 1 (Resident #63) out of 57 residents reviewed during the annual survey.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on review of medical records, review of correspondences, and interviews with staff, it was determined that the facility failed to have complete, appropriate documentation in the medical record to ensure the discharge needs of a resident were met. This was found evident of 1 (Resident #390) of 3 Residents reviewed for discharges.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, 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 1 (Resident #28) out of 3 Residents reviewed for Activity of Daily Living (ADL) cares.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on medical record reviews and interviews, it was determined that 1) the facility staff failed to maintain supervision of a resident to minimize the risk for falls. This was evident for 1 (Resident #224) out of 9 residents reviewed for accidents during the annual survey. 2) The facility staff failed to provide treatments according to a Resident ' s plan of care. This was found evident of 1 (Resident #382) out of 4 residents reviewed for pressure ulcers.
- D
Post nurse staffing information every day.
Inspectors wroteBased on observations and interviews, it was determined that the facility failed to post updated staffing information daily. This was found evident in 2 of 12 days observed on the 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 review of the facility's Controlled Medication Shift Change Log and interview with staff, it was determined that the facility failed to ensure that an account of all controlled drugs was completed. This was found to be evident for 6 out of 14 logs reviewed during medication administration observation.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to: 1) maintain a safe and effective system for securing medication and treatment supplies and 2) properly store and dispose of medications. This was found to be evident for 1) 3 out of 10 medication carts and 2) 2 of 2 medication storage rooms observed during the annual survey.
- D
Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.
Inspectors wroteBased on record review and interviews, it was determined that the facility failed to have a system in place that assured accurate entry was completed to enable the ability for laboratory specimens to be processed by an outside company. This was found evident in 5 out of 8 laboratory samples reviewed for Resident #28.
- 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 staff interviews, it was determined that the facility failed to properly store food in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared by the facility's kitchen.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observations and staff interviews it was determined that the facility failed to ensure the staff sanitized medical equipment between residents. This was found to be evident for 4 out of 5 residents (Residents #111, #424, #426, and #114) observed for infection control.
October 31, 2019Standard inspection · 2 citations
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interviews with staff and medical record reviews the facility failed to send out written notices to the responsible party for Resident numbers 123, 5, and 81 when discharged to the hospital . This was evident for 3 out of 3 residents transfered to the hospital.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observations, medical record review and resident and staff interview it was determined the facility failed to ensure that fingernails were kept trimmed for Resident #2. This was evident for 1 of 3 residents reviewed for Activities of Daily Living (ADLs) during the survey.
Fire safety inspections
38 fire safety citations on file: 14 on February 26, 2026, 19 on October 16, 2024, 5 on October 31, 2019.
Every fire safety citation38 citations
- F
Establish roles under a Waiver declared by secretary.
E 26 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Ensure that testing and maintenance of electrical equipment is performed.
K 921 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Install proper backup exit lighting.
K 281 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · February 26, 2026 · Corrected (the home has a date of correction)
- E
Have proper medical gas storage and administration areas.
K 923 · February 26, 2026 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · October 16, 2024 · Corrected (the home has a date of correction)
- F
Install a fire alarm system that can be heard throughout the facility.
K 341 · October 16, 2024 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · October 16, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 16, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · October 16, 2024 · Corrected (the home has a date of correction)
- F
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
K 761 · October 16, 2024 · Corrected (the home has a date of correction)
- F
Have restrictions on the use of portable space heaters.
K 781 · October 16, 2024 · Corrected (the home has a date of correction)
- F
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
K 914 · October 16, 2024 · Corrected (the home has a date of correction)
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · October 16, 2024 · Corrected (the home has a date of correction)
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 16, 2024 · Corrected (the home has a date of correction)
- E
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · October 16, 2024 · Corrected (the home has a date of correction)
- E
Install corridor and hallway doors that block smoke.
K 363 · October 16, 2024 · Corrected (the home has a date of correction)
- E
Meet other general requirements that are deficient.
K 500 · October 16, 2024 · Corrected (the home has a date of correction)
- E
Have elevators that firefighters can control in the event of a fire.
K 531 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
K 362 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 16, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · October 31, 2019 · Corrected (the home has a date of correction)
- D
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
K 223 · October 31, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · October 31, 2019 · Corrected (the home has a date of correction)
- D
Meet requirements for the installation and maintenance of electrical systems.
K 911 · October 31, 2019 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · October 31, 2019 · Corrected (the home has a date of correction)