Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Friends Nursing Home during CMS and state inspections, most recent first.
The facility failed to ensure behavioral monitoring was in place for residents receiving psychotropic medications. A resident on Paxil for depression had no psychotropic behavioral monitoring order in the record, and two other residents receiving antidepressants, trazodone, and buspirone also had no behavioral monitoring documentation in their MARs. The DON acknowledged the lack of documentation and stated the facility did not have behavioral monitoring records for those residents.
Surveyors found incomplete refrigerator temperature logs, improper storage of ice cream tubs on the freezer floor, and salad dressings lacking expiration dates. During a follow-up, cold food items such as cheese, eggs, turkey, and hot dogs were stored above the required 41°F, indicating failures in food storage and temperature monitoring.
Surveyors found that multiple resident rooms had missing cove base in bathrooms, gaps between walls and floor tiles, black patches of growth, stained and missing floor tiles, and a lack of enclosed space for hanging clothing. These deficiencies were observed during facility rounds and confirmed in staff interviews, with the administrator noting that repairs had been delayed due to supply back orders following flood damage.
A resident with bilateral hand contractures and limited range of motion did not have a care plan addressing the use of hand splints or OT interventions. The interdisciplinary team, including nursing and OT staff, did not collaborate to create or update a care plan reflecting the resident's needs and therapy goals, despite documentation of contractures and the use of new orthotic devices.
A resident with hand contractures and limited range of motion did not have an updated care plan reflecting OT interventions or the use of hand/wrist splints. Despite OT involvement and recommendations, the care plan was not revised, and nursing staff used alternative measures such as rolled washcloths. The DON and Director of Rehabilitation confirmed the absence of a care plan addressing these needs.
A resident with limited mobility and a sacral wound experienced ongoing, unmanaged pain, including episodes of screaming and complaints of burning, despite having orders for scheduled and PRN pain medication. Staff failed to administer as-needed Tramadol for several days and did not consistently follow the care plan for pain management, resulting in inadequate relief and documentation of the resident's pain.
A resident with a stage IV pressure ulcer requiring Enhanced Barrier Precautions was not clearly identified within a shared room, and staff were unaware of which individual required these precautions. Additionally, the facility's Antibiotic Stewardship policy had not been reviewed or updated annually as required, with no documentation of review since 2018.
Surveyors found that call bell boxes in two resident rooms were hanging from the wall with exposed wires, indicating that essential equipment was not kept in safe operating condition. This was confirmed by the NHA, who stated that maintenance addresses such issues when they occur.
Two residents experienced serious injuries—one with burns from spilled hot coffee and another with multiple fractures of unknown origin. In both cases, the facility did not report the incidents to authorities within the required two-hour window and failed to complete investigations within five days, as mandated.
A resident reported being physically abused by a staff member, but the facility failed to notify the state survey agency within the required two-hour timeframe. The resident, with a history of serious medical conditions, reported the incident to a therapist, but the notification to the Administrator and subsequent report to the state agency were delayed, violating the facility's policy and the Elder Justice Act.
A resident was administered medicated eye drops intended for post-surgery use, despite the surgery not occurring. The error was due to a lack of communication and awareness among staff, including an LPN and the Assistant Director of Nursing, who followed the MAR without verifying the surgery status. The issue was identified after the previous DON informed the staff involved.
Missing behavioral monitoring for residents on psychotropic medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had behavior monitoring interventions in place. During the annual survey, review of records and staff interviews identified this issue for 3 of 5 residents reviewed for unnecessary medication use. Resident #31 was receiving Paxil 10 mg at bedtime for depression, but the record did not show an order for psychotropic behavioral monitoring at the time of review. The DON acknowledged that behavior monitoring is part of the process for residents on psychotropics, and the facility policy stated that behavioral monitoring should be implemented for residents on psychotropics such as anti-anxiety medications, antidepressants, and hypnotics. Resident #70 was receiving Prozac 40 mg daily and Remeron 15 mg at bedtime for depression, and the MAR for December 2025 and January 2026 did not contain behavioral monitoring documentation for either medication. Resident #73 was receiving Prozac 30 mg in the morning, Trazodone 100 mg at bedtime, and Buspirone 7.5 mg three times daily for mood, and the MAR for October and November 2025 also lacked behavioral monitoring documentation for these psychotropic medications. When asked to provide documentation, the DON stated that the facility did not have behavioral monitoring records for these residents' psychotropic medications.
Deficient Food Storage and Temperature Monitoring
Penalty
Summary
Surveyors identified multiple failures in food storage, monitoring, and service during kitchen inspections. Temperature logs for all seven refrigerators were found to be incomplete for two consecutive shifts. In the walk-in freezer, nine large tubs of ice cream were observed stored directly on the floor. Additionally, in the walk-in refrigerator, two containers of salad dressing were labeled only with handwritten dates on the lids, lacking any expiration or use-by dates. During a follow-up visit, cold food items at the deli holding station and its refrigerator were found to be stored above the required 41°F, with temperatures ranging from 41.7°F to 44.0°F for various items including cheese, hard-boiled eggs, turkey, and hot dogs. These findings were confirmed through direct observation and temperature checks with facility staff.
Deficient Environmental Maintenance in Resident Rooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a homelike environment for residents, as evidenced by multiple deficiencies in 13 resident rooms. Specifically, bathrooms in these rooms were missing cove base around the entire perimeter, resulting in a half-inch gap between the wall and floor tiles. In one bathroom, black patches of growth were noted at the rear base of the toilet, extending from the missing cove base area up the wall, with exposed and peeling paint. Additionally, floor tiles in one room were stained brown and rust in color near the head of the bed, and several rooms had missing floor tiles with exposed cement flooring. One room lacked an enclosed space for hanging clothing for resident use. During an interview, the Nursing Home Administrator stated that the cove base had been on back order for about a year due to flood damage that occurred approximately a year prior. These observations were made during facility rounds and interviews, and all findings were directly related to the physical environment and its failure to meet standards for safety, cleanliness, and comfort as required for residents.
Failure to Develop and Update Care Plan for Resident with Hand Contractures
Penalty
Summary
The facility failed to create, revise, and update a comprehensive care plan in a timely manner for a resident with significant physical limitations. Specifically, the resident was observed with bilateral hand contractures and was using white knit tube stockings on both arms, but was not wearing hand splints. The resident required maximum assistance with eating and drinking and was non-verbal at the time of observation. Review of the electronic medical record revealed that there was no care plan addressing the use of hand splints or occupational therapy (OT) interventions related to the resident's limited range of motion. Further investigation showed that the OT staff had not participated in any care plan meetings with the interdisciplinary team since a specified date, and there was no care plan referencing the use of bilateral hand orthotics or splints. The OT evaluation and plan of treatment documented a diagnosis of contractures of the bilateral hands and wrists, with a goal for the resident to tolerate bilateral hand orthotics without skin changes. However, there was no evidence that the interdisciplinary team, including nursing, had created a care plan reflecting these OT goals or the use of the new air pump style splint, which also lacked a physician order.
Failure to Update Care Plan for OT Interventions and Hand Splint Use
Penalty
Summary
The facility failed to revise and update a resident's care plan in a timely manner following the initiation of occupational therapy (OT) interventions for hand contractures. The resident, who was non-verbal and required maximum assistance with eating and drinking, was observed with white knit tube stockings on their contracted hands and arms, but was not wearing prescribed hand splints. Review of the electronic medical record revealed that there was no care plan addressing the use of hand splints or OT interventions for the resident's limited range of motion, despite OT involvement beginning over two months prior. The annual MDS assessment, which documented functional limitations in range of motion, had been completed, but the care plan was not updated to reflect the resident's current needs or the OT recommendations. Interviews with the DON confirmed that nursing staff were responsible for applying the splints and that OT had started working with the resident, but interventions such as rolled washcloths were being used instead. The DON acknowledged that interventions for the resident's hand contractures should have been included in the care plan and updated as OT recommendations changed. Further, the Director of Rehabilitation stated that rehabilitation staff had not participated in care plan meetings and that there was no care plan created in collaboration with nursing regarding the hand splints. The lack of an updated care plan persisted throughout the period of OT intervention.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident who required such services, as evidenced by multiple observations and interviews. The resident, who had limited physical mobility and a sacral wound, was observed on several occasions expressing significant pain, including verbal complaints of burning and screaming that could be heard in the hallway. The resident's son reported that the resident frequently complained of pain, especially when wet, and expressed dissatisfaction with the timeliness of care. On one occasion, the resident used the call bell due to pain but expressed fear that staff would not respond. Although a nurse responded within three minutes and acknowledged the resident's ongoing pain, it was revealed that the resident had not received their as-needed Tramadol for several days, despite ongoing complaints of pain. Review of the resident's care plan indicated that pain medication was to be administered as ordered, with effectiveness evaluated and side effects monitored. The care plan also specified offering pain medication prior to wound care and documenting and reporting pain complaints. However, the resident's pain was not managed according to these standards, as evidenced by the lack of timely administration of prescribed pain medication and insufficient evaluation of pain relief. Staff interviews confirmed that the resident was frequently in pain, and the care plan interventions were not consistently implemented.
Failure to Maintain Infection Control Precautions and Annual Policy Review
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in two key areas. During observation rounds, an Enhanced Barrier Precautions sign was posted on the door of a resident room, but there was no indication as to which resident within the shared room the precautions applied to. When interviewed, a GNA staff member was unable to identify which resident required the enhanced barrier precautions. Review of medical records revealed that a resident in the room had a facility-acquired stage IV pressure ulcer requiring these precautions, but this information was not clearly communicated or identified for staff. Additionally, the facility did not conduct an annual review of its Infection Prevention and Control Program (IPCP), specifically the Antibiotic Stewardship policy. The policy was last revised in August 2018 and was due for review in August 2019. When asked for documentation of annual review, the administrator was unable to provide any evidence that the policy had been reviewed or updated since 2018, only noting that updating policies was an area needing attention.
Failure to Maintain Safe Call Bell Equipment
Penalty
Summary
Surveyors observed that essential equipment, specifically call bell boxes, were not maintained in safe operating condition in two out of thirteen resident rooms reviewed. During observation rounds, call bell boxes were found hanging from the wall with blue wires exposed. This deficiency was identified through direct observation and confirmed during an interview with the Nursing Home Administrator, who acknowledged that maintenance repairs the call boxes when they are dislodged.
Failure to Timely Report and Investigate Serious Injuries
Penalty
Summary
The facility failed to timely report allegations involving serious bodily injury and did not complete investigations within the required timeframes. In one incident, a resident sustained second-degree burns with clustered blisters on the left thigh after spilling hot coffee during breakfast. The incident occurred on 1/14/25, but the facility did not begin its investigation until 1/16/25 and did not report the incident to the State Survey Agency until 1/21/25, which exceeded the required two-hour reporting window for serious injuries. Additionally, the facility did not complete and submit the investigation report within the mandated five-day period, as the closure was not reported until 1/29/25. In another case, a resident was found with bruising and diagnosed with a displaced clavicle fracture and multiple rib fractures. The facility became aware of these injuries on 2/10/25, but did not submit the initial Facility Reported Incident (FRI) to the Office of Health Care Quality until the following day, missing the two-hour reporting requirement. The resident, who had moderate cognitive impairment and spoke Bengali, denied falling or being abused, and staff reported no witnessed falls or incidents. Despite the injuries being of unknown origin, the facility did not adhere to the required reporting timeframe.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the state survey agency within the required two-hour timeframe. The incident involved a resident who reported being physically abused by a staff member. The resident, who had a medical history including dissection of the carotid artery, nontraumatic subarachnoid hemorrhage, hypertension, and anxiety disorder, was admitted to the facility on January 4, 2024. The resident had intact cognition and required partial/moderate assistance with various activities of daily living. On January 5, 2024, the resident reported to a physical therapist that they were struck four times on the arm by a staff member the previous night. This report was documented by the Assistant Director of Nursing at 11:51 AM. Despite the facility's policy requiring immediate reporting of abuse allegations, the state survey agency was not notified until 8:00 PM, over eight hours after the initial report was documented. The facility's Administrator was informed of the allegation at 6:00 PM, after leaving the facility, and subsequently filed the report. The delay in reporting violated the facility's policy and the Elder Justice Act, which mandates that abuse resulting in serious bodily injury be reported within two hours of knowledge. This deficiency highlights a failure in the facility's abuse reporting protocol, as staff did not notify the Administrator promptly, leading to a delayed report to the state survey agency.
Failure to Follow Physician's Order for Post-Surgical Eye Drops
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of medicated eye drops for a resident who was scheduled for cataract surgery. The order specified that the eye drops were to be administered three times daily for seven days following the surgery. However, the eye drops were administered prior to the surgery, which never occurred. This error was documented in the Medication Administration Record (MAR) and was carried out by multiple staff members, including the Assistant Director of Nursing and a licensed practical nurse. Interviews with staff revealed a lack of communication and awareness regarding the resident's surgical status. The licensed practical nurse and the Assistant Director of Nursing both administered the eye drops under the assumption that the surgery had taken place, as the order was present on the MAR. The error was only discovered after the previous Director of Nursing informed the staff involved. The current Director of Nursing acknowledged that the orders were not followed as written, and the facility's Administrator confirmed that the eye drops should not have been administered.
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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 Sandy Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brooke Grove Rehab. & Nsg Ctr | 1.2 mi | ★★★★★ | 2 | 0 |
| Bedford Court Healthcare Cent. | 3.5 mi | ★★★★★ | 25 | 0 |
| Layhill Nursing And Rehabilitation Center | 3.8 mi | ★★★★★ | 42 | 0 |
| Harmony Suites Rehabilitation And Wellness Center | 4.2 mi | ★★★★★ | 6 | 1 |
| Fairland Center | 5.4 mi | ★★★★★ | 4 | 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.