Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Fahrney-keedy Memorial Home during CMS and state inspections, most recent first.
Lack of Qualified Dietetic Service Supervision: The facility failed to ensure a full-time, qualified dietetic service supervisor oversaw food prep and daily kitchen operations. The Director of Culinary Services stated he was not a CDM and only received limited consultation from a regional CDM, while the DON reported that CDM had not worked for the company for about six months. The facility also could not provide credible evidence that the contracted RD or a qualified CDM provided current oversight, consultation, or education to kitchen staff, and the Director of Culinary Services had expired ServSafe credentials.
Failure to Provide Ordered Treatments and Medications: Two residents did not receive multiple ordered treatments, medications, and care interventions as documented on the MAR/TAR. One resident had chronic pain, diabetes, respiratory failure, and extensive skin impairment with wounds, rashes, scratches, and bruising, while another resident had chronic pain and other medical conditions with a care plan for symptom management. The DON stated an agency LPN failed to complete assigned treatments and care, and the facility identified the issue after missing documentation and an unchanged dressing were noted.
The facility failed to store and prepare food according to professional standards, with several opened and expired items found in the refrigerator. Additionally, dietary aides were observed mishandling food, such as not changing gloves or washing hands after touching various surfaces, and not wearing hair restraints. These deficiencies were noted during a kitchen inspection.
The facility failed to follow infection control protocols, including droplet precautions for a resident with pneumonia, lacking a Legionella Water Management Program, and not adhering to Enhanced Barrier Precautions (EBP) for residents requiring high-contact care. Staff were observed not wearing appropriate PPE, and the facility's water management policy lacked necessary details. These deficiencies were confirmed through staff interviews and observations.
A resident's dignity was compromised when their urine collection bag was not placed in a privacy bag, making it visible from the hallway. The resident, who had a Foley catheter, was observed during a facility tour, and the RN confirmed the lack of a privacy bag. The DON acknowledged the issue, which was noted as a deficiency in maintaining resident dignity.
The facility failed to conduct thorough investigations for abuse allegations involving three residents. In one case, a resident reported verbal abuse by an LPN, but other residents cared for by the LPN were not assessed. In another case, a resident alleged abuse by agency staff, but the facility did not assess other residents cared for by the staff. In the third case, a resident's abuse complaint was not substantiated, and the investigation lacked interviews with other residents or a medical assessment.
A facility failed to notify a resident and their representative in writing of the bed hold policy upon transfer to a hospital. The resident, who was alert and cognitively intact, was transferred for medical reasons, but the facility did not provide the required documentation. Interviews revealed that the policy was not consistently communicated to long-term residents.
A resident receiving tube feedings had a care plan with conflicting instructions regarding dietary intake supervision. Staff noted the resident as independent, while the Kardex required 1 to 1 supervision for oral intake. Observations showed the resident unsupervised with liquids, highlighting a failure to update the care plan to meet the resident's needs.
A resident with Alzheimer's Dementia, dependent on staff for self-care, was found with long toenails despite a care plan directive to trim them on shower days. The resident's representative had informed staff of the issue weeks prior, but the toenails remained untrimmed until a surveyor's intervention. An LPN and the DON confirmed that the GNAs were responsible for this task, highlighting a lapse in care.
A resident with an indwelling catheter was observed with their urine collection bag placed directly on the floor, contrary to the care plan which required the bag to be positioned below the bladder and away from the entrance. The RN confirmed the observation and corrected the placement by hanging the bag on the bedframe. The DON acknowledged the concern.
A facility failed to serve a meal according to a resident's dietary needs and preferences. A surveyor observed that a meal tray intended for a resident on a mechanical soft diet contained apple pie instead of the specified cinnamon applesauce. The Food Service Manager confirmed the error, acknowledging that the dietary staff should have adhered to the resident's meal ticket. The nursing home administrator was informed of the issue.
A facility failed to report an abuse allegation involving a resident to the State Agency within the required 2-hour timeframe. The resident informed an LPN of the abuse, but the Nursing Home Administrator was not notified until days later, and the state agency was informed even later. The facility lacked documentation to prove timely reporting, as confirmed by interviews with the social services director and DON.
Lack of Qualified Dietetic Service Supervision
Penalty
Summary
The facility failed to ensure a full-time, qualified dietetic service supervisor was in place to oversee food preparation and daily kitchen operations. During interview, the Director of Culinary Services stated he was not certified as a dietary manager and reported receiving consultation from a regional CDM about once a month, sometimes more frequently. The Director of Nursing stated she was not aware of the Director of Culinary Services’ qualifications and reported that the regional CDM had not worked for the contracted culinary service company for about six months, making it impossible for that person to have been providing consultation during that period. The DON also reported that the contracted company provided a Registered Dietitian who worked at the facility every Friday and provided education and oversight to the Director of Culinary Services, but the surveyor requested documentation of that oversight and education. The documentation provided showed three kitchen staff in-services in July 2025, with the Director of Culinary Services and the Manager of Culinary Production listed as training facilitators; no other instructors were identified. The Administrator reviewed the Director of Culinary Services’ credentials and found expired ServSafe certifications, and the facility was unable to provide credible evidence that the contracted RD or a qualified CDM had provided current oversight, consultation, or education to the kitchen staff.
Failure to Provide Ordered Treatments and Medications
Penalty
Summary
The facility failed to ensure that physician-ordered treatments and medications were provided and documented for two residents. Resident #44 had a history that included chronic pain, anxiety, depression, respiratory failure, diabetes, cerebrovascular accident, and self-inflicted skin injuries related to scratching. During observation, the resident was lying in bed with a bandage to the right arm and multiple sores on the forehead and scalp. Review of the skin assessment showed multiple areas of impaired skin integrity, including rashes, lesions, scratches, and bruising on the head, chest, shoulders, axilla, and both upper extremities. The MAR and TAR showed that multiple ordered treatments and interventions were not documented as completed, including wound care, topical medications for itching and pain, skin cream, barrier cream, toileting, positioning, pressure-relief measures, and enhanced barrier precautions. Resident #9 had a history of chronic pain and other medical conditions, and the care plan included treatments and medications to manage those conditions. Review of the MAR and TAR showed that on the identified date, multiple ordered treatments and one medication were not documented as completed, including pain monitoring, TED hose, antifungal powder, acetaminophen, nourishing skin cream, dignity urinary drain bag placement, heel floating, barrier cream, enhanced barrier precautions, suprapubic catheter care, toileting, and repositioning. The DON stated that an agency LPN had been assigned several residents and failed to complete ordered treatments and care, and that the facility identified the issue after missing documentation was noted and Resident #44's dressing was observed not to have been changed as ordered.
Deficient Food Storage and Handling Practices
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards, as observed during a kitchen inspection. The walk-in refrigerator contained several opened food items, such as Greek yogurt, pineapple juice, and various seasonings, without labels indicating their open and use-by dates. Additionally, several other food items, including Italian dressing, chopped garlic, and cooked meats, were found with expired use-by dates. Staff #4, the food services manager, acknowledged the labeling issues and removed the expired items after the surveyor's intervention. Further observations revealed lapses in food handling practices by the kitchen staff. Staff #5, a dietary aide, was seen handling food trays without changing gloves or washing hands after touching various surfaces, including a phone. Staff #7 was observed without a hair restraint while handling food, and Staff #6 used the same gloves to touch a food warmer and then bread without changing them. These actions were brought to the attention of Staff #4, who acknowledged the concerns and indicated that hand hygiene training was provided to staff upon hire and annually.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to proper infection control protocols, as evidenced by multiple deficiencies observed during the survey. Resident #71, diagnosed with pneumonia, was placed on droplet precautions, requiring healthcare personnel to wear an N-95 mask, gown, and gloves. However, a Geriatric Nursing Assistant was observed in the resident's room wearing only a surgical mask, without the necessary gown and N-95 mask, despite the droplet precaution sign posted outside the room. This lapse in protocol was confirmed by the Director of Nursing and acknowledged by the GNA involved. The facility also lacked a comprehensive Legionella Water Management Program. Although a policy was in place, it did not include a detailed description or diagram of the water system, nor did it identify areas prone to Legionella growth. During an interview, the maintenance staff admitted to not having a plan in place to prevent Legionella and other waterborne pathogens, despite understanding the requirements outlined in the policy. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring high-contact care. Resident #85, who had a wound requiring daily dressing changes, was not provided care in accordance with EBP guidelines. An LPN performed a dressing change without wearing a gown and failed to perform hand hygiene between glove changes. Similarly, CNAs providing care to Resident #39, who had a history of MDRO infection, did not wear gowns as required by EBP protocols. These deficiencies were confirmed through interviews with the staff involved and the Director of Nursing.
Failure to Maintain Resident Dignity with Urine Collection Bag
Penalty
Summary
The facility failed to ensure the dignity of a resident by not maintaining privacy for the resident's urine collection bag. During an initial tour, it was observed that the urine collection bag of a resident was not placed in a privacy bag and was visible from the hallway. This observation was made for one of the three residents reviewed for dignity. The resident had been readmitted from the hospital with a Foley catheter in place, and the care plan included positioning the catheter bag and tubing below the bladder level and away from the entrance room door. Upon interviewing the RN assigned to the resident, it was confirmed that the urine collection bag was indeed visible and not in a privacy bag. The RN attempted to find a privacy bag but was unsuccessful. The Director of Nursing was later informed of the issue and acknowledged the concern. The deficiency was noted as the facility did not adhere to the dignity standards by failing to provide a privacy bag for the urine collection bag, which was visible from outside the resident's room.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations for allegations of abuse involving three residents. In the first case, an environmental services aide reported verbal abuse of a resident by an LPN. Although the resident and their roommate were interviewed, there was no documentation of assessments or interviews of other residents cared for by the LPN during that shift. The Director of Nursing (DON) confirmed the lack of documentation for these additional assessments and interviews. In the second case, an allegation of abuse was made by a resident against an agency nursing staff. The facility assessed the resident's skin and obtained statements from the alleged perpetrator and other staff, but did not document assessments or interviews of other residents cared for by the alleged perpetrator. The DON acknowledged this oversight. In the third case, a resident's complaint of abuse was not substantiated after several staff testimonies and an interview with the resident, who was found to be confused. The DON admitted that the investigation did not meet facility expectations, as it lacked interviews with other residents or a resident assessment by a Nurse Practitioner or Physician.
Failure to Notify Resident of Bed Hold Policy
Penalty
Summary
The facility failed to notify a resident and/or their representative in writing of the facility's bed hold policy upon the resident's transfer to an acute care facility. This deficiency was identified during a review of five residents who were hospitalized, specifically affecting one resident. The resident, who was alert, oriented, and cognitively intact, had been residing in the facility since August 2023. A nurse's note indicated that the resident was transferred to the hospital for lethargy, unresponsiveness, and increased tremors on December 22, 2024. However, there was no documentation showing that the facility's bed hold policy was communicated in writing to the resident's representative. Interviews with facility staff revealed inconsistencies in the communication of the bed hold policy. A nursing supervisor mentioned that a packet including the bed hold policy was given to 911 staff during transfers, but the admissions director admitted that the policy was not addressed with long-term residents, including the resident in question. The director of nursing acknowledged the oversight and the nursing home administrator understood the concern regarding the failure to notify the resident and/or representative in writing of the bed hold policy upon transfer.
Inadequate Review and Revision of Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan was reviewed and revised to meet their needs, specifically regarding tube feeding and dietary intake. The resident, who was admitted in early 2024, received nutrients through tube feedings and by mouth. However, the care plan contained conflicting interventions, indicating both independence and the need for supervision during intake. Staff documentation predominantly noted the resident as independent, while the Kardex specified 1 to 1 supervision for any oral intake and a clear liquid diet. Observations and interviews revealed inconsistencies in the care provided. A Geriatric Nursing Assistant (GNA) reported that the resident was a tube feeder but also received meal trays, with staff only setting up the tray and adjusting the bed. During an observation, the resident was seen with a cup of water without supervision, contrary to the Kardex instructions. The Director of Nursing acknowledged the discrepancy and indicated a need to update the care plan and consult with a speech therapist to ensure the resident's safety with liquids.
Failure to Provide ADL Assistance for Resident with Long Toenails
Penalty
Summary
The facility failed to ensure that a resident who could not carry out activities of daily living (ADL) received the necessary care and assistance. This deficiency was identified for a resident with Alzheimer's Dementia, who was observed sitting in a wheelchair with long toenails, despite the resident's representative having informed the staff about this issue three weeks prior. The resident's Minimum Data Set (MDS) assessment indicated a substantial to maximal dependence on staff for self-care needs, and the care plan included an intervention to check and trim nails on bath days. Despite the care plan's directive, the resident's toenails were not trimmed on the designated shower days, as confirmed by an observation and subsequent interviews. A Licensed Practical Nurse (LPN) acknowledged that the Geriatric Nurse Aides (GNAs) were responsible for trimming toenails for residents without diabetes on shower days, yet this task was not completed for the resident in question. The Director of Nursing (DON) also confirmed that the GNAs should have clipped the resident's toenails, indicating a lapse in the facility's adherence to the care plan for the resident's ADL needs.
Inappropriate Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling catheter. This deficiency was identified during an observation on the initial tour of the facility, where a resident was found in bed with their urine collection bag placed directly on the floor. The Registered Nurse assigned to the resident confirmed the observation and subsequently hung the urine collection bag on the bedframe. The resident's care plan, reviewed later, indicated that the resident was readmitted from the hospital with a Foley catheter in place, and included interventions such as positioning the catheter bag and tubing below the level of the bladder and away from the entrance room door, as well as providing catheter care on each shift and as needed. The Director of Nursing acknowledged the concern during an interview.
Failure to Serve Meal According to Resident's Dietary Needs
Penalty
Summary
The facility failed to serve a meal to a resident according to a predetermined menu that incorporated the resident's preferences and dietary needs. During an observation on 1/30/25, a surveyor requested a test tray and noted discrepancies between the meal ticket and the actual meal served to the resident. The meal ticket for the resident specified a mechanical soft diet with cinnamon applesauce as dessert, but the tray contained apple pie instead. The Food Service Manager acknowledged the error, stating that the dietary staff should have provided applesauce, not apple pie, due to the resident's mechanical soft food texture requirement. The nursing home administrator was informed of this issue on 2/3/25.
Failure to Timely Report Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #406 to the State Agency within the required timeframe. The resident reported the abuse to an evening nursing supervisor, an LPN, on the morning of March 1, 2024. However, the Nursing Home Administrator was not informed until March 4, 2024, at 11:15 AM, and the initial report to the state agency was not made until 11:59 AM on the same day. The final report was sent on March 8, 2025. Interviews with the social services director and the director of nursing confirmed that the facility was aware of the allegation on March 1, 2024, and had initiated an investigation, but lacked documentation to prove timely reporting to the state agency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boonsboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| South Mountain Rehab Center | 3.2 mi | ★★★★★ | 15 | 1 |
| Creekside Center For Rehabilitation And Nursing | 5.9 mi | ★★★★★ | 34 | 1 |
| Hagerstown Healthcare Center | 6.9 mi | ★★★★★ | 28 | 0 |
| Julia Manor Nursing And Rehabilitation Center | 6.9 mi | ★★★★★ | 47 | 0 |
| Coffman Nursing Home | 8.8 mi | ★★★★★ | 16 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.