1183 Luther Drive, Hagerstown, MD 21740 (opens Google Maps) · Washington County · (301) 790-1000· 80 certified beds · avg 76 residents/day · certified since Apr 3, 1978 · Medicare and Medicaid certified
Certified for both programmes. Certification means the facility can bill Medicaid — it does not mean a Medicaid-funded bed is free right now, so ask directly. Who pays for nursing home care →
SFF Candidate
What Special Focus status means →
Part of chain: MORDECHAI WEISZ (7 facilities, chain avg rating 2.4★)
New to these records? How to read an inspection report →
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5 · how star ratings work →
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and quality measures from resident assessments and claims.
▲ Immediate jeopardy, isolated · Dec 23, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 24, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, isolated · Aug 5, 2024 · F-0604 · triggered by a complaint
The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment.
Why it matters: Unneeded restraints can cause injuries, muscle loss, and deep emotional distress.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 22, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · Aug 5, 2024 · F-0684 · triggered by a complaint
The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 22, 2024 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, isolated · Jul 25, 2019 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Immediate jeopardy to resident health or safety was cited. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Sep 25, 2019 (Deficient, Provider has date of correction)
▲ Actual harm, isolated · Oct 17, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Feb 4, 2025 (Past Non-Compliance)
▲ Actual harm, isolated · Aug 5, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): Actual harm was cited, below immediate jeopardy. The scope was isolated: limited residents, staff, or locations were affected. Scope describes the extent of the deficiency, not whether it happened on previous inspections.
Corrected: Nov 22, 2024 (Deficient, Provider has date of correction)
Showing the latest 3 of 104 inspection findings. Open the full record below to read every finding.
The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. F-0812
The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. F-0578
The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. F-0550
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed — that window is CMS's, not ours. Within it, every citation CMS publishes for this facility is listed here: none excluded.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Feb 6, 2026 | F · Potential for more than minimal harm, widespread | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · F-0812 |
| Feb 6, 2026 | E · Potential for more than minimal harm, pattern | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · F-0578 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · F-0550 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · F-0636 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · F-0641 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · F-0657 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · F-0697 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · F-0756 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · F-0760 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not educate residents and staff about COVID-19 vaccination, offer the vaccine to those eligible after that education, or properly document everyone's vaccination status. · F-0887 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · F-0919 |
| Feb 6, 2026 | D · Potential for more than minimal harm, isolated | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · F-0947 |
| Dec 23, 2025 | ▲ J · Immediate jeopardy, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Oct 17, 2025 | ▲ G · Actual harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Oct 17, 2025 | E · Potential for more than minimal harm, pattern | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint · F-0609 |
| Oct 17, 2025 | D · Potential for more than minimal harm, isolated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610 |
| Feb 21, 2025 | E · Potential for more than minimal harm, pattern | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint · F-0880 |
| Feb 21, 2025 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656 |
| Feb 21, 2025 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684 |
| Feb 21, 2025 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · from a complaint · F-0757 |
| Aug 5, 2024 | ▲ J · Immediate jeopardy, isolated | The facility used physical restraints — devices that limit a resident's movement — when they weren't needed for medical treatment. · from a complaint · F-0604 |
| Aug 5, 2024 | ▲ J · Immediate jeopardy, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint · F-0684 |
| Aug 5, 2024 | ▲ G · Actual harm, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint · F-0689 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not properly plan a resident's discharge to meet the resident's goals and needs after leaving. · from a complaint · F-0660 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. · F-0727 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not observe each nurse aide's job performance or provide regular training as required. · F-0730 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · F-0835 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. · from a complaint · F-0838 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · F-0880 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not develop or maintain an effective training program for its direct care staff, including training on how to communicate effectively with residents. · F-0941 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. · F-0943 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not include required infection control training — with written standards, policies, and procedures — as part of its infection prevention program. · F-0945 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · F-0947 |
| Aug 5, 2024 | F · Potential for more than minimal harm, widespread | The facility did not provide its staff with required training on behavioral health — caring for residents with conditions like dementia, depression, or other mental health needs. · F-0949 |
| Aug 5, 2024 | E · Potential for more than minimal harm, pattern | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · F-0550 |
| Aug 5, 2024 | E · Potential for more than minimal harm, pattern | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint · F-0610 |
| Aug 5, 2024 | E · Potential for more than minimal harm, pattern | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · F-0623 |
| Aug 5, 2024 | E · Potential for more than minimal harm, pattern | The facility did not make sure the resident's doctor reviewed their care and wrote, signed, and dated progress notes and orders at each required visit. · from a complaint · F-0711 |
| Aug 5, 2024 | E · Potential for more than minimal harm, pattern | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not give residents the required written notice of their rights, the facility's rules, the services offered, and what those services cost. · F-0572 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · F-0578 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint · F-0580 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · F-0602 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · F-0609 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint · F-0622 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · F-0625 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. · F-0637 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint · F-0656 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint · F-0658 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint · F-0677 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint · F-0686 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. · F-0688 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint · F-0692 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint · F-0695 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide safe and appropriate pain management for a resident who needed it. · from a complaint · F-0697 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · F-0698 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. · F-0710 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. · from a complaint · F-0712 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · F-0732 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. · F-0740 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint · F-0744 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · F-0756 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility's quality committee — the internal group responsible for finding and fixing care problems — did not have the required members or did not meet at least every three months. · F-0868 |
| Aug 5, 2024 | D · Potential for more than minimal harm, isolated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. · F-0883 |
| Jul 25, 2019 | ▲ J · Immediate jeopardy, isolated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · F-0689 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · F-0602 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · F-0610 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · F-0656 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · F-0657 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. · F-0676 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. · F-0725 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · F-0755 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. · F-0757 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. · F-0759 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not have enough support staff to safely and effectively run its food and nutrition service. · F-0802 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · F-0842 |
| Jul 25, 2019 | E · Potential for more than minimal harm, pattern | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · F-0867 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · F-0558 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · F-0600 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · F-0609 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. · F-0623 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave. · F-0625 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · F-0655 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · F-0684 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · F-0686 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · F-0692 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. · F-0756 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. · F-0758 |
| Jul 25, 2019 | D · Potential for more than minimal harm, isolated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · F-0835 |
| Jul 25, 2019 | C · Potential for minimal harm, widespread | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. · F-0732 |
| Jul 25, 2019 | B · Potential for minimal harm, pattern | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. · F-0565 |
Citations from standard inspections decreased between the last two inspection cycles (39 → 19).
All bars start at zero. Exact values and supporting details remain below.
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2019 | 27 | 1 | J ▲ |
| 2024 | 50 | 3 | J ▲ |
| 2025 | 8 | 2 | J ▲ |
| 2026 | 19 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
How to file a complaint about care →
2 fines totaling $111,536.
Every penalty CMS publishes for this facility in the 3-year window is listed —none excluded. The count and the dollar total come from two different CMS datasets and agree for this facility. Penalties older than the window are dropped by CMS before publication, not by us.
| Date | Type | Amount / length |
|---|---|---|
| Oct 17, 2025 | Fine | $10,358 |
| Aug 5, 2024 | Fine | $101,178 |
What these staffing numbers mean →
All bars start at zero. Exact values and supporting details remain below.
| Measure | This facility | Maryland avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.24 | 3.83 | 3.95 | bottom 25% in Maryland; bottom 24% in the U.S. |
| Registered Nurse hours | 0.69 | 0.83 | 0.69 | top 48% in Maryland; top 37% in the U.S. |
| Weekend total nurse staffing | 2.89 | 3.43 | 3.50 | bottom 22% in Maryland; bottom 25% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.58 | 0.63 | 0.48 | top 39% in Maryland; top 24% in the U.S. |
| Total nursing staff turnover (%) | 64.7 | 40.2 | 45.8 | bottom 3% in Maryland; bottom 10% in the U.S. |
| RN turnover (%) | 62.5 | 38.7 | 42.9 | bottom 8% in Maryland; bottom 19% in the U.S. |
Hours are per resident per day for the most recent quarter of payroll data in this CMS release (2026-08-01) — the same quarter for every facility — case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.29, RN 0.71, weekend 2.94.Comparing with Medicare Care Compare? Care Compare shows the raw figure (3.29 here, displayed there as hours and minutes), not the adjusted one above. Both are correct; they answer different questions. Staffing rating: 2/5.
Note: CMS combines facility-reported resident assessments (MDS) with claims-based measures. These are different sources from on-site inspection findings. Read the measures alongside inspection and staffing records; a high QM rating does not establish that a home is safe.
Quality measures rating: 4/5 · long-stay residents: 4/5 · short-stay residents: 3/5
Price evidence · separate from quality
No verified facility-specific private-pay price is available in our data for Creekside Center for Rehabilitation and Nursing. CMS inspection and staffing records do not tell us what this home will charge you.
Use a written private-pay quote. This worksheet adds only the amounts you enter; it does not calculate Medicare, Medicaid or insurance benefits.
Formula: (room rate + daily extras) × days + one-time charges. A 30-day scenario is not a calendar-month quote. Refundable deposits, rate changes and charges you omit are not automatically included. Entries are not saved or sent to our server.
Understand who pays for care · How we handle price evidence · Report an incorrect price
How to read ownership records →
Ownership records as published by CMS on 2026-08-01. CMS records when an owner joined but not when they left. Listed here and no longer involved? Tell us →
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Elebiary, Ahmed | Individual | Managing Control - Governing Body | NOT APPLICABLE | 10/01/2022 |
| Elebiary, Ahmed | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Elebiary, Ahmed | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2022 |
| Lions Healthcare Management LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Lions Healthcare Management LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/03/2025 |
| Truslow, Cynthia | Individual | Operational/Managerial Control | NOT APPLICABLE | 12/01/2024 |
| Truslow, Cynthia | Individual | ADP of the SNF | NOT APPLICABLE | 10/01/2022 |
| Weisz, Mordechai | Individual | Managing Control - Governing Body | NOT APPLICABLE | 12/01/2024 |
| Weisz, Mordechai | Individual | ADP of the SNF | NOT APPLICABLE | 12/01/2024 |
All 9 owning or managing parties CMS has on file are shown — none excluded.
CMS lists this facility under the chain Mordechai Weisz — 7 facilities in the current records. Chain membership says who operates these homes. It says nothing about how any individual one of them was inspected; each has its own record.
Listed by state, then facility name — not a ranking.
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Julia Manor Nursing and Rehabilitation Center | 1.1 mi | Hagerstown, MD | ★☆☆☆☆ | 1/5 | abuse |
| Hagerstown Healthcare Center | 1.4 mi | Hagerstown, MD | ★★☆☆☆ | 2/5 | abuse |
| Coffman Nursing Home | 3.2 mi | Hagerstown, MD | ★★★☆☆ | 3/5 | |
| Western MD Hospital Center | 3.5 mi | Hagerstown, MD | ★★★★★ | 3/5 | |
| Homewood Living Williamsport | 4.4 mi | Williamsport, MD | ★★★☆☆ | 3/5 | |
| Williamsport Health and Rehabilitation Center | 5.5 mi | Williamsport, MD | ★☆☆☆☆ | 1/5 | abuse |
| Fahrney-Keedy Memorial Home | 5.9 mi | Boonsboro, MD | ★★★★★ | 5/5 | |
| Complete Care at Hagerstown | 6.0 mi | Hagerstown, MD | ★☆☆☆☆ | 1/5 | |
| South Mountain Rehab Center | 8.6 mi | Boonsboro, MD | ★★★☆☆ | 3/5 | |
| Canterbury Center | 13.6 mi | Shepherdstown, WV | ★★☆☆☆ | 2/5 | |
| Quincy Retirement Community | 14.9 mi | Waynesboro, PA | ★★★★☆ | 4/5 | |
| Martinsburg Healthcare Center | 15.8 mi | Martinsburg, WV | ★★★★☆ | 3/5 |
Facility data as of CMS processing date 2026-08-01. CCN 215113.
This page is the printable visit checklist. If your browser did not open the print dialog automatically, use File → Print (Ctrl/⌘-P).
May we use Google Analytics cookies to measure visits and pages viewed? Optional — every feature works without them. Privacy details