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STATE OF MARYLAND CENTRAL PAYROLL BUREAU

HAGERSTOWN, MD · Washington County · Government - State · 63 certified beds

📍 1500 Pennsylvania Avenue, Hagerstown, MD 21742  ·  📞 (301) 745-4200

Medicare ID: 215110  ·  Last Medicare inspection: Jun 4, 2024

Overall Safety Score
59
out of 100
Fair
Component Scores
14
Inspection
100
Staffing
48
Enforcement
45
Complaints
91
Quality
📋 Last inspected: June 4, 2024 📦 CMS data as of: May 2026

Score Breakdown

Inspection
14
Staffing
100
Enforcement
48
Complaints
45
Quality Outcomes
91

What the numbers mean

STATE OF MARYLAND CENTRAL PAYROLL BUREAU scored 59 out of 100 — 5 points below the state average of 64.

📋 Inspections: 26 citations over the last 36 months — 1 fewer than the state average (27). 2 were rated serious (G+) — inspectors found actual or potential harm to residents.

👥 Staffing: Staffing levels are strong — RN hours and total nurse hours per resident are in the favorable range. Adequate staffing is one of the most important factors in resident safety.

⚠️ Penalties & enforcement: CMS has recorded 2 enforcement actions totaling $24,060 against this facility. Penalties are only issued after a facility fails two levels of regulatory review — meaning this is a serious escalation beyond a standard citation. Ask for a written explanation of every fine and what corrective actions were taken.

⚠️ Complaints: Above-average complaint activity. Complaint surveys are unannounced and targeted — they often surface problems that routine annual inspections miss. Ask management about the nature of complaints filed and how each was resolved.

💚 Resident quality outcomes: This facility's star-rated quality measures are in the strong range. Key indicators like fall rates, antipsychotic use, and vaccination coverage compare favorably to national benchmarks — a positive signal for day-to-day resident care.

What inspectors found (last 3 surveys)

26
Total citations
State avg: 27
2
Serious (G+)
State avg: 0.7
0
Repeat findings

Top concern areas

26

⚖ Penalties & Enforcement

Federal civil monetary penalties (CMPs) are only issued after a facility has failed two levels of regulatory review — meaning problems were found on inspection and the facility could not rebut the findings. This is a serious escalation beyond a standard citation.

$24,060
Total federal fines
2
Enforcement actions

⚠ Each enforcement action required CMS to make a separate non-compliance determination — meaning this facility failed two levels of regulatory review before any fine was issued. Ask management specifically what violations triggered these fines and what corrective steps were taken.

📋 Enforcement Context Analysis
📊
Enforcement score: 48/100 — 27 points below the state average of 75/100 — worse than most comparable facilities. A score below 70 indicates a meaningful enforcement history that warrants direct conversation with facility management.
Serious Citations That May Have Triggered Enforcement
Respiratory care — Immediate danger · Jun 4, 2024
F0578 — Resident was harmed · Jun 4, 2024
Food sanitation & safety — No harm, could worsen · Jun 4, 2024

📅 Per-action enforcement records (date, fine amount, and penalty type for each individual action) are sourced from a separate CMS enforcement dataset and will be added in a future data update.

🩹

Resident Wellbeing — Key Indicators

These are the measures families ask about most. They come from CMS clinical assessments of every resident — not just inspection reports. Stars (★) count toward the official CMS quality star rating.

Antipsychotic medication use
0.0% lower is better
Share of long-stay residents given antipsychotic drugs. High use can signal residents being over-medicated rather than receiving attentive care.
Flu vaccination rate
5.1% higher is better
Share of long-stay residents vaccinated against the flu this season. Higher is better.

Source: CMS MDS Quality Measures & Medicare claims data. Scores shown are the most recent 4-quarter averages for long-stay residents.

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🟡
Overall Assessment — Use Caution  ·  59/100
This facility has mixed results. Some areas need a closer look before you decide.
What to do next: Proceed carefully. Ask management directly about the specific concerns listed in this report.
Federal Penalty: $24,060 (2 separate actions)
CMS has imposed civil monetary penalties totaling $24,060 against this facility. Penalties are only levied after a separate non-compliance determination — meaning a facility must fail two levels of regulatory review before a fine is issued. Ask management specifically what violations triggered these fines and what corrective actions were taken.

What this facility's data shows

📋 Inspections
Inspection record is well below average. Multiple or serious deficiencies found.
👥 Staffing
Staffing levels are adequate — RN hours and nurse-to-resident ratios meet or exceed benchmarks.
⚖ Penalties
Facility has received federal fines or enforcement sanctions. Requires direct explanation from management.
💬 Complaints
Higher-than-average complaint volume. Complaint surveys are often triggered by serious resident concerns.
Quality outcome measures are strong — fall rates, antipsychotic use, and other key indicators compare favorably to national benchmarks.
⚠ Serious Findings on Record: 2 citation(s) where inspectors found actual harm or immediate jeopardy to residents. See Section D for the full details and ask management how each was resolved.
Score breakdown — the numbers behind this assessment
👥 Staffing 100
What it measures RN hours per resident per day, total nurse hours, and RN turnover rate.
💡 Understaffing is the strongest single predictor of poor inspection outcomes.
📋 Inspection 14
What it measures Number, severity (A–L), and scope of deficiencies found. Repeat findings carry extra weight.
💡 Every citation in Section D feeds directly into this score.
⚖ Penalties 48
What it measures Whether CMS escalated from a deficiency citation to actual financial or operational sanctions.
💡 A penalty means the facility already failed a second level of regulatory review.
💬 Complaints 45
What it measures Volume of complaint-triggered inspections and the share that were substantiated.
💡 Complaint surveys are unannounced — they often surface issues annual surveys miss.
🎯 Quality outcomes 91
What it measures Resident outcome measures: falls, pressure ulcers, antipsychotic use, weight loss, hospitalizations.
💡 Reflects the lived experience of residents beyond what inspectors observe.

Each pillar scores 0–100 and is combined into the overall score. A strong overall can mask a weak pillar — compare all four and see how they stack against the state average in Section B.

🏗 How This Facility Compares to MD State Averages

Comparing a facility to others in the same state puts its score in context. A facility might have 8 citations and that could be above average in one state and below in another. Green means this facility is doing better than its peers; red means it's falling short.

Metric This facility MD avg vs. State
Overall score
The combined Senior Care Report Card score out of 100.
59 64 ▼ Worse than state avg
Inspection score
How well the facility performs on standard health surveys.
14 54 ▼ Worse than state avg
Staffing score
RN hours, total nurse hours, and staff turnover from CMS payroll data.
100 62 ▲ Better than state avg
Penalty score
Fines, payment denials, and enforcement actions on file.
48 75 ▼ Worse than state avg
Complaint score
Volume of complaint surveys and substantiated complaints.
45 70 ▼ Worse than state avg
Quality score
Resident clinical outcomes vs national benchmarks: falls, antipsychotics, pain, vaccination, hospitalizations.
91 57 ▲ Better than state avg
Citations (3 yrs)
Total number of deficiencies cited in the last 36 months.
26 27 ▲ Better than state avg
Serious citations
Citations rated severity G or higher (actual harm or immediate jeopardy).
2 0.7 ▼ Worse than state avg

📅 Inspection Timeline

State health inspectors visit nursing homes on a regular cycle — typically every 12 to 15 months — and document every deficiency they find. The timeline below shows the date and scale of each inspection visit over the past several years. A pattern of worsening surveys is a red flag even if the most recent visit looks clean.

2024-06-04
26 citations  (2 serious)
2019-05-24
4 citations
2018-02-14
5 citations

Bar length proportional to citation count. Red = serious findings (severity G+). Orange = elevated. Green = low.

📄 Full Citation Record

Every time state inspectors visit a nursing home, they write up anything that doesn’t meet federal standards. Each write-up is called a citation.

Each citation shows what the problem was and how serious it was, using a color-coded badge:

Green — No residents harmed Yellow — Risk of harm, no injury Orange — A resident was harmed Red — Life or safety in danger

A Repeat tag means the same problem appeared in a previous inspection — it was not fully corrected the first time. Citations shown cover the last two years.

Survey: 2024-06-04 26 citation(s) — 2 serious
F0695 Immediate danger
Respiratory care
F0578 Resident was harmed
F0578
F0812 No harm, could worsen
Food sanitation & safety
F0838 No harm, could worsen
Facility assessment update
F0909 No harm, could worsen
Maintain equipment in good condition
F0843 No harm, could worsen
F0843
F0656 No harm, could worsen
Comprehensive care plan
F0868 No harm, could worsen
Facility assessment
F0657 No harm, could worsen
Care plan timing & review
F0684 No harm, could worsen
Quality of care
F0842 No harm, could worsen
Medical records accuracy & security
F0686 No harm, could worsen
Pressure ulcer prevention & treatment
F0610 No harm, could worsen
Investigate & correct violations
F0623 No harm, could worsen
Notice before transfer or discharge
F0867 No harm, could worsen
Quality assurance program
F0726 No harm, could worsen
Nurse aide competency
F0756 No harm, could worsen
Drug regimen review
F0622 No harm, could worsen
Transfer or discharge requirements
F0761 No harm, could worsen
Medication storage & labeling
F0609 No harm, could worsen
Timely reporting of alleged violations
F0791 No harm, could worsen
Physician services arrangement
F0757 No harm, could worsen
Unnecessary drugs
F0584 No harm, could worsen
F0584
F0559 No harm, could worsen
F0559
F0677 No harm, could worsen
Personal hygiene & grooming assistance
F0758 No harm, could worsen
Unnecessary psychotropic drugs
🩹

How Are Residents Doing?

Inspections tell you whether a facility followed the rules. These measures tell you how residents actually fared — whether they fell, experienced pain, lost weight, or were over-medicated. CMS collects this data through regular clinical assessments that nurses complete for every resident. Unlike inspections, which happen once a year, these assessments happen continuously.

⚠ Attention: 2 of 7 star-rated measures show rates above what\'s typically considered acceptable. This means the facility may be struggling in areas that directly affect residents\' day-to-day wellbeing — not just its inspection record.

How to read these cards: Each card shows one measure. Lower percentages are better for most (e.g. fewer falls), but higher is better for vaccination rates and community return. ★ Star rating marks measures CMS uses in its official quality star rating.

Long Stay Residents — 2025Q1-2025Q4
★ Star rating
Daily activity decline
5.3% lower is better
Share of long-stay residents who lost the ability to dress, eat, or move around independently over the past year. Rising rates can signal that residents aren't receiving enough physical therapy or that staffing is too thin to support mobility.
★ Star rating
Urinary tract infections
0.0% lower is better
Share of long-stay residents who had a urinary tract infection. While some UTIs are unavoidable, high rates can point to poor hydration practices, catheter hygiene, or rushed care routines.
★ Star rating
Antipsychotic medication use
0.0% lower is better
Share of long-stay residents given antipsychotic drugs. These medications carry serious risks for older adults. High use often signals that a facility is medicating residents to manage behavior instead of addressing needs through attentive, person-centered care.
★ Star rating
Percentage of long-stay residents experiencing on…
1.6% lower is better
Percentage of long-stay residents experiencing one or more falls with major injury
★ Star rating
Flu vaccination rate
5.1% higher is better
Share of long-stay residents vaccinated against the flu. Nursing homes are high-risk environments for flu outbreaks. Anything below 90% warrants a question about the facility's vaccination policy.
★ Star rating
Percentage of long-stay residents with pressure u…
6.5% lower is better
Percentage of long-stay residents with pressure ulcers
★ Star rating
Percentage of long-stay residents who received an…
32.4% lower is better
Percentage of long-stay residents who received an antipsychotic medication
Physical restraints used
1.6% lower is better
Share of long-stay residents physically restrained (lap belts, side rails). Federal regulations require restraints to be a last resort. High use is a red flag for understaffed facilities cutting corners on behavioral care.
Signs of depression
1.5% lower is better
Share of long-stay residents showing symptoms of depression. Social isolation, lack of meaningful activities, and poor staffing all contribute. This measure reflects the emotional quality of life inside the facility.
Unexplained weight loss
0.0% lower is better
Share of long-stay residents who lost 5% or more of body weight unexpectedly. This can indicate inadequate nutrition, difficulty eating without assistance, or unaddressed medical issues.
Percentage of long-stay residents assessed and ap…
93.2% lower is better
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
Pneumonia vaccination rate
34.7% higher is better
Share of long-stay residents vaccinated against pneumococcal pneumonia — one of the leading causes of death in older adults. Higher is better.
Percentage of long-stay residents assessed and ap…
100.0% lower is better
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
Percentage of long-stay residents with new or wor…
14.0% lower is better
Percentage of long-stay residents with new or worsened bowel or bladder incontinence

Source: CMS MDS Quality Measures (2025Q1-2025Q4). Collected via standardized clinical assessments — not inspector visits.

💬 Questions to Ask Before Touring

These questions are generated specifically from this facility's score profile and citation history — not a generic checklist. A facility's willingness to answer them openly, and the quality of their answers, is itself an important signal. Bring this list when you tour or call.

  1. Federal inspectors found 2 citations rated as causing actual harm or immediate jeopardy in the public record. Walk us through each incident: what happened, who was affected, and what specific policy or staffing changes have been put in place since?
  2. This facility has a significant CMS enforcement history. Can you identify each action in the past three years, what it was for, and what systemic — not just procedural — changes were made to prevent recurrence?
  3. Complaint data shows a higher-than-average volume of formal complaints filed with the state. What were the most common categories last year, and how does your resolution process work from the moment a complaint is filed?
  4. 2 citations in the public record were rated as causing actual harm to a resident. Can you describe what occurred in each case and what specific safeguards are now in place?
  5. Can we speak privately with two or three current residents or their families?

👪 Family Decision Guide

This guide translates this facility's data into practical next steps for families. It is not a recommendation for or against placement — it is a structured framework for the conversations you need to have before making a decision.

✓ Positives to confirm

  • Staffing levels appear adequate — ask about weekend and night coverage
  • No pattern of repeat violations detected

⚠ Areas to probe

  • Inspection score is low — ask for the most recent state survey results
  • Penalty history present — ask what enforcement actions occurred and outcomes
  • Elevated complaint activity — ask how resident concerns are investigated
  • Serious-harm citations on record — require a written explanation of corrective action
  • Always speak with at least two current residents or family members independently

📈 Score History

The score is recalculated every time CMS releases updated data (typically monthly). A consistent downward trend is more concerning than a single low score. An improving trend after a period of poor performance may indicate management changes are taking effect. Your subscription will alert you whenever the score changes materially.

2026-05-07
59 — Fair

🏢 Ownership & Operators

Ownership matters because large corporate chains sometimes prioritize cost controls over care quality. CMS requires every nursing home to disclose its owners, operators, and managing employees. Frequent ownership changes can disrupt staffing and operations — which is why we flag facilities that changed ownership in the past 12 months.

🔗 EDMONDS, KELLY operates 1 facility across .
Owner / Operator Role Ownership % Effective
EDMONDS, KELLY Individual 1970-01-01
DEVILBISS, KELLY Individual 1970-01-01
BROY-STEVENSON, NEDINA Individual 1970-01-01
STATE OF MARYLAND CENTRAL PAYROLL BUREAU Organization 1970-01-01
WATTS, WAYNE Individual 1970-01-01

🔔 Monthly tracking is now free

We check CMS data monthly. Use the tracking form above and we will email you when new citations appear, scores change, or enforcement actions are added.

📋
Monthly report update
New citation alerts
📈
Score trend tracking
🏠 Verify this data on Medicare.gov
All data in this report comes from the CMS Care Compare database. You can review the official public record directly on Medicare.gov — including the full inspection narrative, star ratings, and any recent enforcement actions.
View on Medicare.gov ↗

This report reflects publicly available CMS data only and is updated monthly. Severity codes and narratives are reproduced directly from the CMS health inspection database. Senior Care Report Card scores are independently computed and are not affiliated with or endorsed by CMS or Medicare.gov.

Data source: CMS Care Compare · Methodology · State Ombudsman

This report uses public CMS nursing home data and simplified scoring to help families ask better questions. It is not a recommendation, ranking, medical opinion, legal opinion, or substitute for an in-person visit. Source data last published by CMS: May 4, 2026.