Inspection Report Summary
The most recent inspection on November 5, 2025, identified deficiencies related to inappropriate resident discharges, failure to inform residents about care limitations, and improper use of psychotropic medications. Earlier inspections showed a pattern of issues including incomplete abuse investigations, delayed physician notifications, and multiple resident care and medication management deficiencies. Prior reports also noted problems with care planning, infection control, and quality assurance. Complaint investigations were mostly substantiated, with notable findings about discharge practices and abuse investigation shortcomings. The facility’s inspection history indicates ongoing challenges with resident care communication and medication oversight, with no clear trend of improvement or worsening over time.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
53% better than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Nov 5, 2025
Visit Reason
The inspection was conducted to investigate complaints regarding inappropriate discharges of residents needing hospice or long-term care, failure to inform residents about care limitations, improper use of psychotropic medications, and failure to provide required discharge notices.
Complaint Details
The complaint alleged that Resident #3 was inappropriately discharged from the facility because it was medically unsafe and that the facility pressured the family to discharge the resident due to hospice care needs. The family was not informed of care limitations at admission and was not issued a 30-day discharge notice. The complaint also involved concerns about Resident #4's discharge related to dementia and memory care needs.
Findings
The facility was found to have inappropriately discharged residents needing hospice or long-term care without proper documentation or notice, failed to inform residents and representatives about care limitations at admission, improperly used psychotropic medications without adequate monitoring or dose reduction, and failed to issue 30-day discharge notices as required.
Deficiencies (5)
Failed to honor the wishes of the resident representative and allow the resident to stay at the facility while receiving hospice services.
Failed to ensure that residents were free of chemical restraints and that PRN psychotropics were limited to 14 days.
Failed to inform residents and/or resident representatives about limitations in the care services provided.
Discharged residents without appropriate reason and failed to appropriately document the discharge.
Failed to issue a 30-day notice to residents when planning to discharge them.
Report Facts
Residents reviewed for discharge: 2
Psychotropic medication administration occasions: 9
Dates related to Notice of Medicare Non-Coverage (NOMNC): 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Informed family about discharge due to hospice care needs, issued NOMNC, and participated in utilization review meetings. |
| Director of Nursing | Director of Nursing (DON) | Reported on discharge practices related to hospice care and rehab, and acknowledged deficiencies in monitoring psychotropic medications. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Confirmed discharge reasons and facility policies regarding hospice and long-term care. |
| RN #2 | Registered Nurse | Administered lorazepam to Resident #4 without proper documentation. |
| Nurse Practitioner #1 | Nurse Practitioner (NP) | Provided progress notes and medication orders for Resident #4. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 25, 2025
Visit Reason
The inspection was conducted due to a recertification and complaint survey focusing on allegations of abuse at the facility.
Complaint Details
The complaint investigation found that the facility did not conduct thorough investigations for abuse allegations involving 2 residents out of 8 investigated. The Director of Nursing confirmed the lack of staff and resident interviews and statements.
Findings
The facility failed to ensure a thorough investigation was completed for allegations of abuse involving two residents. Specifically, the investigations lacked staff and resident interviews and statements.
Deficiencies (2)
Failed to ensure a thorough investigation was completed for allegations of abuse, including failure to interview staff and obtain statements for Resident #189.
Failed to ensure a thorough investigation was completed for allegations of abuse, including failure to interview residents, staff and obtain statements for Resident #180.
Report Facts
Residents investigated for abuse: 8
Residents with incomplete investigations: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the facility's failure to conduct thorough investigations and confirmed missing staff and resident interviews and statements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 25, 2021
Visit Reason
The inspection was conducted due to a complaint investigation related to the facility's failure to promptly notify the ordering physician of laboratory results for one resident.
Complaint Details
The complaint investigation found that the facility did not notify the physician of the TSH lab results until after the surveyor inquired, indicating a failure in timely communication.
Findings
The facility staff failed to promptly notify the ordering physician of a thyroid-stimulating hormone (TSH) test result for Resident #122, which was reported by the lab on 02-16-2021 but not communicated until after the surveyor inquired on 02-24-2021.
Deficiencies (1)
Failed to promptly notify the ordering practitioner of laboratory test results for Resident #122.
Report Facts
Residents reviewed for unnecessary medications: 5
Residents affected: 1
TSH test result: 8.37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed about the pending TSH result and provided the lab result after surveyor inquiry |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 3, 2019
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations, including resident care, food safety, and equipment maintenance at Tuckerman Rehabilitation and Healthcare Center.
Findings
The facility was found deficient in providing timely treatment and care to a resident with urinary symptoms, maintaining sanitary food storage and handling practices, and ensuring safe operation of essential equipment such as an electrically powered air mattress.
Deficiencies (3)
Facility staff failed to provide timely treatment and care for a resident experiencing burning on urination, with no documentation of assessment or physician notification.
Facility staff failed to store and serve food under sanitary conditions, including rotting lemons, unlabeled and uncovered food items, and presence of butane cartridges near food.
Facility staff failed to inspect and maintain an electrically powered air mattress in safe operating condition, with the mattress found deflated on multiple occasions.
Report Facts
Residents selected for review: 17
Rooms served by staff #4: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding resident care and equipment maintenance findings | |
| Dietary Manager | Interviewed regarding food storage and handling findings |
Inspection Report
Complaint Investigation
Deficiencies: 13
Date: May 14, 2018
Visit Reason
The inspection was conducted based on complaint investigations and review of clinical records, staff practices, and interviews related to multiple resident care concerns including advance directives, notification of changes, care planning, medication management, infection control, and quality assurance.
Complaint Details
The visit was complaint-related, triggered by multiple concerns including failure to honor advance directives, medication errors, inadequate care planning, infection control breaches, and quality assurance deficiencies. Specific substantiation status is not stated.
Findings
The facility was found deficient in honoring residents' advance directives, notifying responsible parties of treatment changes, developing baseline and comprehensive care plans, providing appropriate treatment and care according to orders, managing medication regimens properly, safeguarding resident information, maintaining infection control practices, and conducting effective quality assurance monitoring.
Deficiencies (13)
Facility staff failed to honor an individual's advance directives for 2 of 3 residents reviewed (#1, #22).
Facility staff failed to notify responsible parties when a change of treatment was made for 2 of 2 residents reviewed (#12, #20).
Facility staff failed to develop a baseline care plan within 48 hours after admission for 1 of 5 residents (#73).
Facility staff failed to develop a person-centered care plan for 2 of 16 residents (#11, #122).
Facility staff failed to provide basic life support including CPR according to resident preferences and physician orders for 1 of 1 resident (#22).
Facility staff failed to provide appropriate treatment and care according to orders and resident preferences for 4 of 16 residents (#1, #73, #20, #122).
Facility staff failed to ensure a resident was free from unnecessary drugs, specifically prolonged use of Bacitracin for 1 of 7 residents (#7).
Facility staff failed to implement gradual dose reductions and appropriate use of psychotropic medications for 2 of 7 residents (#12, #20).
Facility staff failed to ensure medication error rates were below 5%, with a 7.4% error rate observed during medication administration.
Facility staff failed to maintain garbage storage in a sanitary condition, with overflow and improper storage observed.
Facility staff failed to obtain psychiatric nurse practitioner's progress notes timely for 3 of 16 residents (#12, #20, #21).
Quality Assurance committee failed to monitor complaints and grievances and evaluate quality of care for a deceased resident.
Facility staff failed to use correct transmission-based precautions for 2 residents with infections (#16, #122).
Report Facts
Medication administration error rate: 7.4
Number of residents affected: 2
Number of residents affected: 2
Number of residents affected: 1
Number of residents affected: 2
Number of residents affected: 1
Number of residents affected: 4
Number of residents affected: 1
Number of residents affected: 2
Number of residents affected: 3
Number of residents affected: 2
Number of cardboard boxes observed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed multiple times regarding findings related to advance directives, medication errors, care planning, and infection control. | |
| Director of Rehabilitation | Interviewed regarding CPR initiation and care concerns for resident #22. | |
| Administrator | Interviewed regarding quality assurance and facility operations. | |
| Psychiatric Nurse Practitioner | Involved in medication orders and progress notes for residents #12, #20, and #21. | |
| Nurse (staff #3) | Observed medication administration error for resident #21. | |
| Charge Nurse (staff #2) | Interviewed regarding infection control practices. |
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