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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K1 | L· |
| Actual harm | G4 | H· | I· |
| Potential harm | D92 | E80 | F47 |
| Minimal | A· | B· | C5 |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Aug 19, 2026 | Health | Health Complaint | 3 | Actual harm | 2 | Open → |
| Jul 2, 2026 | Health | Health Complaint | 1 | Actual harm | — | Open → |
| Mar 12, 2026 | Health | Health Complaint | 12 | Potential harm | — | Open → |
| Sep 4, 2025 | Fire safety | Fire Safety Standard | 20 | Potential harm | — | Open → |
| Sep 4, 2025 | Health | Health Complaint, Health Standard | 38 | Potential harm | — | Open → |
| Mar 19, 2025 | Health | Health Complaint | 37 | Immediate jeopardy | — | Open → |
| Sep 28, 2022 | Fire safety | Fire Safety Standard | 27 | Potential harm | — | Open → |
| Sep 28, 2022 | Health | Health Standard | 64 | Immediate jeopardy | — | Open → |
| Oct 25, 2018 | Fire safety | Fire Safety Standard | 0 | No citations | — | Open → |
| Oct 25, 2018 | Health | Health Standard | 28 | Potential harm | — | Open → |
| Date | Type | Amount | Payment denial | Record |
|---|---|---|---|---|
| Jul 2, 2026 | Civil money penalty (fine) | $27,378 | — | 215010|Fine|144521 |
| Jul 2, 2026 | Civil money penalty (fine) | $19,635 | — | 215010|Fine|144522 |
| Mar 19, 2025 | Civil money penalty (fine) | $24,088 | — | 215010|Fine|10164 |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J1 | K1 | L· |
| Actual harm | G4 | H· | I· |
| Potential harm | D92 | E80 | F47 |
| Minimal | A· | B· | C5 |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Aug 19, 2026 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | No plan of correction | Complaint |
| Aug 19, 2026 | F-0585 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: — (case-mix index —).
CMS legal business name of the certified provider. Operates this facility only.
7 facilities in 1 states. CMS chain ID 767.
Chain average overall rating (CMS): 1.3
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Md4 Holdco, LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Apr 1, 2023 |
| Md5 Investors LLC | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Apr 1, 2023 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Md4 Holdco, LLC | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Apr 1, 2023 |
| Md5 Investors LLC | Organization | Indirect owner | INDIRECT OWNERSHIP INTEREST | not provided | Apr 1, 2023 |
| Sara Ausch | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Jun 11, 2025 |
| Menashe Eisen | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Apr 9, 2025 |
| Facility | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|
| Caroline Nursing and Rehab 520 Kerr Avenue, Denton, MD 21629 CCN 215083 | 87 | Mar 13, 2026 | 100 | — | |
| Hartley Nursing and Rehab 1006 Market Street, Pocomoke City, MD 21851 CCN 215134 | 73 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| Willowbrooke Ct Skilled Care Ctr at Bayleigh Chase 501 Dutchman's Lane, Easton, MD 21601 CCN 215137 | 0.4 km | 99 | Mar 25, 2026 | 691 IJ1 harm | — |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 215010 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 215010 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
| Maryland OHCQ Long Term Care MD | 2420002 | state_license, licensed_beds, licensee Linked to the CMS record by exact normalized street address and ZIP (the state roster does not publish the CCN). | Inferred | Jul 22, 2025 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Complaint |
| Aug 19, 2026 | F-0940 | Develop, implement, and/or maintain an effective training program for all new and existing staff members. Administration Deficiencies · Administration & records | E · Potential harm Pattern | Past non-compliance | Complaint |
| Jul 2, 2026 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Aug 17, 2026 | Complaint |
| Mar 12, 2026 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 28, 2026 | Complaint |
| Mar 12, 2026 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Apr 28, 2026 | Complaint |
| Sep 4, 2025 | K-0161 | Use approved construction type or materials. Construction Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0293 | Have properly located and lighted "Exit" signs. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0500 | Meet other general requirements that are deficient. Services Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0525 | Enure that solid fuel-burning fireplaces are not in patient sleeping areas. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0711 | Provide a written emergency evacuation plan. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 7, 2025 |
| Sep 4, 2025 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 7, 2025 |
| Sep 4, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0553 | Allow resident to participate in the development and implementation of his or her person-centered plan of care. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0572 | Give residents a notice of rights, rules, services and charges. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 | Complaint |
| Sep 4, 2025 | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0585 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 10, 2025 | Complaint |
| Sep 4, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 10, 2025 | Complaint |
| Sep 4, 2025 | F-0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0640 | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 | Complaint |
| Sep 4, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0807 | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0868 | Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 10, 2025 | Complaint |
| Sep 4, 2025 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 10, 2025 | Complaint |
| Sep 4, 2025 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Nov 10, 2025 |
| Sep 4, 2025 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Nov 10, 2025 |
| Mar 19, 2025 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | J · Immediate jeopardy Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | G · Actual harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0552 | Ensure that residents are fully informed and understand their health status, care and treatments. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0610 | Respond appropriately to all alleged violations. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0758 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Jun 16, 2025 | Complaint |
| Mar 19, 2025 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0840 | Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected May 27, 2025 | Complaint |
| Mar 19, 2025 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0925 | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Jun 20, 2025 | Complaint |
| Mar 19, 2025 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected May 27, 2025 | Complaint |
| Sep 28, 2022 | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies · Clinical care | K · Immediate jeopardy Pattern | Corrected Mar 18, 2023 |
| Sep 28, 2022 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | G · Actual harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | K-0100 | Meet other general requirements. Construction Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0232 | Have corridors or aisles that are unobstructed and are at least 8 feet in width. Egress Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0281 | Install proper backup exit lighting. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0300 | Meet other general requirements that are deficient. Egress Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0344 | Have an alternate power supply for its alarm system. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 24, 2023 |
| Sep 28, 2022 | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 24, 2023 |
| Sep 28, 2022 | K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. Smoke Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0500 | Meet other general requirements that are deficient. Services Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0511 | Have properly installed electrical wiring and gas equipment. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0525 | Enure that solid fuel-burning fireplaces are not in patient sleeping areas. Services Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Feb 24, 2023 |
| Sep 28, 2022 | K-0700 | Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Feb 24, 2023 |
| Sep 28, 2022 | K-0781 | Have restrictions on the use of portable space heaters. Miscellaneous Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | F · Potential harm Widespread | Corrected Jan 18, 2023 |
| Sep 28, 2022 | K-0923 | Have proper medical gas storage and administration areas. Gas, Vacuum, and Electrical Systems Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Jan 18, 2023 |
| Sep 28, 2022 | F-0550 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Mar 18, 2023 |
| Sep 28, 2022 | F-0602 | Protect each resident from the wrongful use of the resident's belongings or money. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0622 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0624 | Prepare residents for a safe transfer or discharge from the nursing home. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0638 | Assure that each resident’s assessment is updated at least once every 3 months. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0661 | Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0679 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0680 | Ensure the activities program is directed by a qualified professional. Quality of Life and Care Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 18, 2023 |
| Sep 28, 2022 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0688 | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0700 | 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. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0710 | Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. Nursing and Physician Services Deficiencies · Staffing & supervision | D · Potential harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0711 | Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0712 | Ensure that the resident and his/her doctor meet face-to-face at all required visits. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0726 | 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. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0741 | Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. Quality of Life and Care Deficiencies · Clinical care | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Mar 18, 2023 |
| Sep 28, 2022 | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies · Medication management | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0761 | 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. Pharmacy Service Deficiencies · Medication management | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0775 | Keep complete, dated laboratory records in the resident's record. Administration Deficiencies · Administration & records | D · Potential harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0790 | Provide routine and 24-hour emergency dental care for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0803 | 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. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0805 | Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0825 | Provide or get specialized rehabilitative services as required for a resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0835 | Administer the facility in a manner that enables it to use its resources effectively and efficiently. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0838 | 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. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Mar 18, 2023 |
| Sep 28, 2022 | F-0850 | Hire a qualified full-time social worker in a facility with more than 120 beds. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · Administration & records | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0881 | Implement a program that monitors antibiotic use. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0883 | Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0886 | Perform COVID19 testing on residents and staff. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0887 | 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. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0909 | Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0921 | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0943 | Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | F · Potential harm Widespread | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0947 | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Nursing and Physician Services Deficiencies · Staffing & supervision | F · Potential harm Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0577 | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Resident Rights Deficiencies · Resident rights & abuse/neglect | C · Minimal Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | C · Minimal Widespread | Corrected Mar 3, 2023 |
| Sep 28, 2022 | F-0625 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | C · Minimal Widespread | Corrected Nov 27, 2022 |
| Sep 28, 2022 | F-0732 | Post nurse staffing information every day. Nursing and Physician Services Deficiencies · Staffing & supervision | C · Minimal Widespread | Corrected Nov 27, 2022 |
| Oct 25, 2018 | F-0559 | Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0565 | Honor the resident's right to organize and participate in resident/family groups in the facility. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0578 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0584 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Freedom from Abuse, Neglect, and Exploitation Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Past non-compliance May 10, 2018 |
| Oct 25, 2018 | F-0623 | Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Resident Rights Deficiencies · Resident rights & abuse/neglect | E · Potential harm Pattern | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0625 | 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. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0697 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0725 | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Medication management | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0791 | Provide or obtain dental services for each resident. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0809 | Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies · Environment & life safety | E · Potential harm Pattern | Corrected Dec 1, 2018 |
| Oct 25, 2018 | F-0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. Environmental Deficiencies · Environment & life safety | D · Potential harm Isolated | Corrected Dec 1, 2018 |
| Yehudis Klein | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Apr 9, 2025 |
| Barry Perlstein | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Apr 9, 2025 |
| Naftali Schlussel | Individual | Partner | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | not provided | Apr 9, 2025 |
| Dianna Gilligan | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 1, 2023 |
| Yechiel Hirth | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 1, 2023 |
| Daniel Howard | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Apr 1, 2023 |
| Key Health Management LLC | Organization | Additional disclosable party | ADP OF THE SNF | not provided | Apr 1, 2023 |
| Dianna Gilligan | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 1, 2023 |
| Daniel Howard | Individual | Additional disclosable party | ADP OF THE SNF | not provided | Apr 1, 2023 |
| Jan 23, 2026 |
631 IJ |
| — |
| Denton Nursing and Rehab 420 Colonial Drive, Denton, MD 21629 CCN 215149Abuse icon | 100 | Jul 15, 2026 | 1212 harm | $19k |
| Manokin Nursing and Rehab 11974 Edgehill Terrace, Princess Anne, MD 21853 CCN 215179SFF CandidateAbuse icon | 135 | Jul 1, 2026 | 1074 IJ1 harm | $27k |
| Mallard Bay Nursing and Rehab 520 Glenburn Avenue, Cambridge, MD 21613 CCN 215191Abuse icon | 160 | Aug 28, 2026 | 1154 open | — |
| Chestertown Nursing and Rehab 415 Morgnec Road, Chestertown, MD 21620 CCN 215260 | 92 | Aug 13, 2025 | 107 | $3,418 |