Total nurse staffing hours per resident per day, case-mix adjusted
Registered nurses: 0.66 hours per resident per day
Nursing staff turnover: 69% a year
Derived by CMS from the Payroll-Based Journal and refreshed quarterly.
Inspection history
Inspected February 6, 2026
19 citations · from a complaint investigation · Health
D
F0550No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0636No actual harm with potential for more than minimal harm · Isolated
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0641No actual harm with potential for more than minimal harm · Isolated
Ensure each resident receives an accurate assessment.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0657No actual harm with potential for more than minimal harm · Isolated
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0689No actual harm with potential for more than minimal harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0760No actual harm with potential for more than minimal harm · Isolated
Ensure that residents are free from significant medication errors.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0880No actual harm with potential for more than minimal harm · Isolated
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0887No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0919No actual harm with potential for more than minimal harm · Isolated
Make sure that a working call system is available in each resident's bathroom and bathing area.
Deficient, Provider has date of correction · corrected March 31, 2026
D
F0947No actual harm with potential for more than minimal harm · Isolated
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Deficient, Provider has date of correction · corrected March 31, 2026
E
F0578No actual harm with potential for more than minimal harm · Pattern
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.
Deficient, Provider has date of correction · corrected March 31, 2026
F
F0812No actual harm with potential for more than minimal harm · Widespread
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Deficient, Provider has date of correction · corrected March 31, 2026
Inspected December 23, 2025
1 citation · from a complaint investigation · Health
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Past Non-Compliance · corrected November 24, 2025
Inspected October 17, 2025
3 citations · from a complaint investigation · Health
D
F0610No actual harm with potential for more than minimal harm · Isolated
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected December 3, 2025
E
F0609No actual harm with potential for more than minimal harm · Pattern
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected December 3, 2025
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Past Non-Compliance · corrected February 4, 2025
Inspected February 21, 2025
4 citations · from a complaint investigation · Health
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected March 31, 2025
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected March 31, 2025
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected March 31, 2025
E
F0880No actual harm with potential for more than minimal harm · Pattern
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected March 31, 2025
Inspected August 5, 2024
50 citations · from a complaint investigation · Health
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0565No actual harm with potential for more than minimal harm · Isolated
Honor the resident's right to organize and participate in resident/family groups in the facility.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0572No actual harm with potential for more than minimal harm · Isolated
Give residents a notice of rights, rules, services and charges.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0578No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 22, 2024
D
F0580No actual harm with potential for more than minimal harm · Isolated
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0602No actual harm with potential for more than minimal harm · Isolated
Protect each resident from the wrongful use of the resident's belongings or money.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0622No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 22, 2024
D
F0625No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected November 22, 2024
D
F0637No actual harm with potential for more than minimal harm · Isolated
Assess the resident when there is a significant change in condition
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0656No actual harm with potential for more than minimal harm · Isolated
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0658No actual harm with potential for more than minimal harm · Isolated
Ensure services provided by the nursing facility meet professional standards of quality.
Deficient, Provider has date of correction · corrected November 22, 2024
D
F0677No actual harm with potential for more than minimal harm · Isolated
Provide care and assistance to perform activities of daily living for any resident who is unable.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0688No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0695No actual harm with potential for more than minimal harm · Isolated
Provide safe and appropriate respiratory care for a resident when needed.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0697No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate pain management for a resident who requires such services.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0698No actual harm with potential for more than minimal harm · Isolated
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0710No actual harm with potential for more than minimal harm · Isolated
Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0712No actual harm with potential for more than minimal harm · Isolated
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Deficient, Provider has date of correction · corrected November 22, 2024
D
F0732No actual harm with potential for more than minimal harm · Isolated
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0740No actual harm with potential for more than minimal harm · Isolated
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0744No actual harm with potential for more than minimal harm · Isolated
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0755No actual harm with potential for more than minimal harm · Isolated
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0757No actual harm with potential for more than minimal harm · Isolated
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0842No actual harm with potential for more than minimal harm · Isolated
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0868No actual harm with potential for more than minimal harm · Isolated
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Deficient, Provider has date of correction · corrected October 8, 2024
D
F0883No actual harm with potential for more than minimal harm · Isolated
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Deficient, Provider has date of correction · corrected October 8, 2024
E
F0550No actual harm with potential for more than minimal harm · Pattern
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Deficient, Provider has date of correction · corrected October 7, 2024
E
F0610No actual harm with potential for more than minimal harm · Pattern
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected October 8, 2024
E
F0623No actual harm with potential for more than minimal harm · Pattern
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected November 22, 2024
E
F0711No actual harm with potential for more than minimal harm · Pattern
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Deficient, Provider has date of correction · corrected October 8, 2024
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected October 8, 2024
F
F0660No actual harm with potential for more than minimal harm · Widespread
Plan the resident's discharge to meet the resident's goals and needs.
Deficient, Provider has date of correction · corrected November 22, 2024
F
F0727No actual harm with potential for more than minimal harm · Widespread
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Deficient, Provider has date of correction · corrected October 8, 2024
F
F0730No actual harm with potential for more than minimal harm · Widespread
Observe each nurse aide's job performance and give regular training.
Deficient, Provider has date of correction · corrected November 22, 2024
F
F0835No actual harm with potential for more than minimal harm · Widespread
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Deficient, Provider has date of correction · corrected November 22, 2024
F
F0838No actual harm with potential for more than minimal harm · Widespread
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.
Deficient, Provider has date of correction · corrected November 22, 2024
F
F0867No actual harm with potential for more than minimal harm · Widespread
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected November 22, 2024
F
F0880No actual harm with potential for more than minimal harm · Widespread
Provide and implement an infection prevention and control program.
Deficient, Provider has date of correction · corrected November 22, 2024
F
F0941No actual harm with potential for more than minimal harm · Widespread
Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.
Deficient, Provider has date of correction · corrected November 22, 2024
F
F0943No actual harm with potential for more than minimal harm · Widespread
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Deficient, Provider has date of correction · corrected October 8, 2024
F
F0945No actual harm with potential for more than minimal harm · Widespread
Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.
Deficient, Provider has date of correction · corrected October 8, 2024
F
F0947No actual harm with potential for more than minimal harm · Widespread
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Deficient, Provider has date of correction · corrected November 22, 2024
F
F0949No actual harm with potential for more than minimal harm · Widespread
Provide behavior health training consistent with the requirements and as determined by a facility assessment.
Deficient, Provider has date of correction · corrected November 22, 2024
G
F0689Actual harm · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected November 22, 2024
J
F0604Immediate jeopardy to resident health or safety · Isolated
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Deficient, Provider has date of correction · corrected November 22, 2024
J
F0684Immediate jeopardy to resident health or safety · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected November 22, 2024
Inspected July 25, 2019
27 citations · Health
B
F0565No actual harm with potential for minimal harm · Pattern
Honor the resident's right to organize and participate in resident/family groups in the facility.
Deficient, Provider has date of correction · corrected September 25, 2019
C
F0732No actual harm with potential for minimal harm · Widespread
Post nurse staffing information every day.
Deficient, Provider has date of correction · corrected November 19, 2019
D
F0558No actual harm with potential for more than minimal harm · Isolated
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0600No actual harm with potential for more than minimal harm · Isolated
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0609No actual harm with potential for more than minimal harm · Isolated
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0623No actual harm with potential for more than minimal harm · Isolated
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0625No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0655No actual harm with potential for more than minimal harm · Isolated
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0684No actual harm with potential for more than minimal harm · Isolated
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0686No actual harm with potential for more than minimal harm · Isolated
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0692No actual harm with potential for more than minimal harm · Isolated
Provide enough food/fluids to maintain a resident's health.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0756No actual harm with potential for more than minimal harm · Isolated
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0758No actual harm with potential for more than minimal harm · Isolated
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.
Deficient, Provider has date of correction · corrected September 25, 2019
D
F0835No actual harm with potential for more than minimal harm · Isolated
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Deficient, Provider has date of correction · corrected September 25, 2019
E
F0602No actual harm with potential for more than minimal harm · Pattern
Protect each resident from the wrongful use of the resident's belongings or money.
Deficient, Provider has date of correction · corrected September 25, 2019
E
F0610No actual harm with potential for more than minimal harm · Pattern
Respond appropriately to all alleged violations.
Deficient, Provider has date of correction · corrected September 25, 2019
E
F0656No actual harm with potential for more than minimal harm · Pattern
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Deficient, Provider has date of correction · corrected September 25, 2019
E
F0657No actual harm with potential for more than minimal harm · Pattern
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Deficient, Provider has date of correction · corrected November 19, 2019
E
F0676No actual harm with potential for more than minimal harm · Pattern
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Deficient, Provider has date of correction · corrected September 25, 2019
E
F0725No actual harm with potential for more than minimal harm · Pattern
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Deficient, Provider has date of correction · corrected November 19, 2019
E
F0755No actual harm with potential for more than minimal harm · Pattern
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Deficient, Provider has date of correction · corrected September 25, 2019
E
F0757No actual harm with potential for more than minimal harm · Pattern
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Deficient, Provider has date of correction · corrected November 19, 2019
E
F0759No actual harm with potential for more than minimal harm · Pattern
Ensure medication error rates are not 5 percent or greater.
Deficient, Provider has date of correction · corrected November 19, 2019
E
F0802No actual harm with potential for more than minimal harm · Pattern
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Deficient, Provider has date of correction · corrected September 25, 2019
E
F0842No actual harm with potential for more than minimal harm · Pattern
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has date of correction · corrected November 19, 2019
E
F0867No actual harm with potential for more than minimal harm · Pattern
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Deficient, Provider has date of correction · corrected September 25, 2019
J
F0689Immediate jeopardy to resident health or safety · Isolated
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has date of correction · corrected September 25, 2019
Penalties
Date
Type
Amount
October 17, 2025
Fine
$10,358
August 5, 2024
Fine
$101,178
Ownership transfers
Effective
Seller
Buyer
10/01/2022
Diakon Lutheran Senior Living - Maryland LLC
Creekside SNF Operating Company LLC
From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.