Above average — CMS composite of the measures below.
The next survey window likely opens around March 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 Pickersgill Retirement Community during CMS and state inspections, most recent first.
Surveyors identified an ongoing pest problem on the nursing unit, with repeated mice sightings documented over several months in resident rooms, hallways, and dining areas, as well as a snake in a storage room. Despite the presence of traps and bait stations, a mouse was directly observed running across the main hallway, and a resident reported seeing mice on multiple occasions. The Director of Maintenance and Executive Director acknowledged mice activity and prior complaints, and health inspection records noted mouse droppings. An interior hallway door near the kitchen was also observed left open to the outside environment, contributing to the failure to maintain a pest-free environment.
Kitchen food safety standards were not followed when three loose food storage bins for panko bread crumbs, flour, and sugar were observed with dirty, crusty, or stained exterior surfaces and food debris on the bread crumb container’s interior rim. A drain near the dishwasher was also observed open with no cover and containing food debris and trash, and the emergency water supply was found to be expired, damaged, and not current.
The facility failed to document that a resident’s SNF to Hospital Transfer Form was provided to the receiving hospital before transfer. During record review and DON interviews, the facility stated that EMTs were given the form for the hospital, but no copy of the form or progress note could be located to confirm that the hospital received the resident’s information prior to transfer.
The facility failed to maintain complete MAR/TAR documentation for two residents. One resident receiving Mirtazapine had no consistent licensed nursing documentation of antidepressant side effect or behavior monitoring, and the DON acknowledged the monitoring order was not in place until after the concern was raised. Another resident with dementia and esophageal dyskinesia had missing MAR documentation for scheduled doses of Diltiazem HCl and Seroquel, which the DON confirmed during review.
The facility staff failed to label canned goods and opened food items with expiration and used by dates. During a kitchen observation, a surveyor found canned goods without expiration dates and an open box of crackers without a known expiration date. Additionally, an open carton of heavy whipping cream lacked a label for the open and discard dates, which the Dietary Chef acknowledged should have been done.
The facility failed to maintain resident dignity and respect by placing over-the-door organizers containing personal care items, including briefs, on the outside of resident room doors. A resident expressed privacy concerns and dissatisfaction with this arrangement, indicating a lack of understanding of its purpose.
A facility failed to protect a resident's medical record confidentiality when a medication cart was left unlocked with a computer screen displaying sensitive information. An RN later secured the cart and closed the screen, admitting she was distracted by a resident need and did not follow protocol.
Facility staff failed to accurately update the MDS assessments for three residents, leading to deficiencies in reflecting their medical conditions. A resident's stage 3 pressure ulcer was not documented as unhealed, another resident's pressure ulcer injury was omitted, and a third resident's multiple wounds were not recorded. The inaccuracies were due to reliance on incorrect staff documentation and progress notes.
A facility failed to provide care based on professional standards for a resident with a skin condition. A bruise-like area on the resident's clavicle was not documented, and the Quality Assurance Nurse was unaware of it until informed by a surveyor. The facility had transitioned to online documentation for weekly skin checks, during which the resident's checks were missed, leaving no records available.
The facility failed to follow oxygen therapy orders and post cautionary signs for residents receiving oxygen. A resident was observed receiving oxygen at a higher rate than prescribed, and the nasal cannula was not changed as required. Additionally, two residents receiving oxygen therapy did not have cautionary signs on their doors, as confirmed by the DON.
The facility failed to obtain informed consent and document alternatives before using bed rails for two residents. Observations revealed that both residents had bed rails installed without proper documentation. The Director of Rehabilitation and the DON were unable to provide reasons or documentation for the use of bed rails, indicating a lapse in the facility's compliance with required procedures.
The facility did not conduct annual performance reviews for four GNAs, as revealed during an annual survey. The surveyor requested documentation for the years 2023 and 2024, but the DON admitted the facility was non-compliant in providing these reviews.
A facility was found to have a medication error rate of 11.54%, exceeding the acceptable threshold of less than 5%. Errors included a missed dose of Bicalutamide for a resident, incorrect administration of Ophthalmic solution to another resident, and improper application of OcuSoft Lid Scrub to a third resident. These discrepancies were confirmed through observation, record review, and interviews with the DON.
A significant medication error occurred when a nurse documented administering five medications to a resident, including Bicalutamide 50MG, which was not observed to be given. A pill count revealed inconsistencies with the administration records, confirming the error.
The facility did not perform regular inspections of bed frames, mattresses, and bed rails to identify potential entrapment risks. Two residents were observed with raised 1/4 bed rails, and the Director of Maintenance could not provide documentation of routine entrapment assessments. Maintenance checks did not include these assessments for residents with transfer bars or bed rails.
The facility did not ensure GNAs completed the required 12 hours of in-service training annually. During a survey, it was found that one GNA received 3 hours, another 5 hours, and a third received no training in 2024. The DON confirmed the facility's non-compliance.
Ongoing Mice Infestation and Pest Sightings on Nursing Unit
Penalty
Summary
The facility failed to ensure the environment was free from pests on the nursing unit, as evidenced by ongoing mice activity and other pests despite the presence of pest control devices. A complaint was filed regarding mice in a specific resident’s room, and during multiple tours of the nursing unit, surveyors observed various pest control devices, including bait stations and traps, in resident rooms. The Director of Maintenance acknowledged that mice had been present on the LTC unit and reported that exterminator services and various pest control methods were in place. Review of the pest sighting log showed repeated documentation of mice and other pests over several months, including mouse droppings on a recliner chair, a mouse running in a room reported by family, mice “swinging from the drape,” mice in the dining room and hallway, and an entry stating “Mice all over the place, the mice is back.” The log also documented a brown snake in a second-floor storage room and a resident’s refusal to have a mouse trap in their room, preferring an alternate method of elimination. Surveyors also identified environmental conditions that could contribute to pest entry and continued presence. Health inspection reports from several months earlier documented mouse droppings, and the Executive Director acknowledged receiving a complaint about a mouse sighting in the room of the resident named in the complaint. During the survey, an interior hallway door near the kitchen was observed left open to the outside environment on more than one occasion. While conducting an infection control observation, a surveyor directly observed a mouse running across the main hallway between resident rooms. A resident independently reported seeing a mouse that day and a few days prior. These observations and documented sightings demonstrated that pests, particularly mice, were present on the nursing unit and in common areas, and that the facility did not maintain an environment free of pests.
Kitchen Food Storage, Drain Sanitation, and Emergency Water Supply Deficiencies
Penalty
Summary
The facility failed to follow professional standards for food service safety in the kitchen. During observation, three loose food storage bins containing panko bread crumbs, flour, and sugar were found with unclean exterior surfaces and visible food debris or staining. The bread crumb bin had a greasy, crusty appearance with tan food debris on the outside, and when the lid was removed, brown food debris was seen near the top rim inside the container. The flour bin had a cloudy appearance with crusty food debris on the exterior, and the sugar bin had a tan food stain on the exterior. The facility also failed to maintain a drain near the dishwasher in a sanitary condition and failed to keep the emergency water supply current. The drain was observed open with no cover and contained food debris and small pieces of trash. The emergency water supply was observed to be outdated, with no gallons within current date, several damaged gallons, some empty gallons with droplets of water present, and one sealed 2025 gallon that was approximately three-quarters full. The Administrator stated that all emergency water was expired.
Missing Documentation of Hospital Transfer Information
Penalty
Summary
The facility failed to provide documentation showing that the receiving hospital was given the resident’s information before the resident was transferred to the hospital. This deficiency was identified for Resident #33 during a record review conducted as part of an annual recertification survey focused on hospitalizations and discharges. The record review showed that Resident #33 was hospitalized on [DATE]. During interviews, the DON stated that when emergency medical technicians arrive to transport a resident to the hospital, the facility provides them with a completed SNF to Hospital Transfer Form for the receiving hospital. The DON said the facility provided Resident #33’s SNF to Hospital Transfer Form at the time of transfer, but the facility did not keep a copy of the form. When asked for documentation showing that the hospital received the form, the DON was unable to locate any progress note or other record indicating that the facility provided the receiving hospital with Resident #33’s SNF to Hospital Transfer Form prior to transfer.
Missing Medication Monitoring and Administration Documentation
Penalty
Summary
The facility failed to ensure documentation of medication side effect monitoring and to maintain medical records in accordance with accepted professional standards for two residents reviewed for unnecessary medications. For one resident, the record showed an active order for Mirtazapine for depression, but the surveyor found no consistent documentation of side effect or behavior monitoring by licensed nursing staff. During interview, the DON stated that side effect monitoring was normally documented on the MAR/TAR and checked every shift, but later acknowledged there was no side effect monitoring order in place and that it had only been added after the surveyor raised the concern. The DON also confirmed there was no further documentation available from licensed nursing staff beyond general behavior monitoring by GNA staff. For another resident with diagnoses including hypertension, GERD, anxiety disorder, adjustment disorder with mixed anxiety and depressed mood, dementia with behavioral disturbance, and esophageal dyskinesia, the record included physician orders for Diltiazem HCl and Seroquel scheduled for 2:00 PM. Review of the MAR showed that the resident did not receive the scheduled 2:00 PM doses on two separate dates in February and March 2026. When the surveyor reviewed the MAR with the DON, the DON confirmed the missing documentation of medication administration for those scheduled doses.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The facility staff failed to ensure that canned goods and dry food were labeled with expiration dates, and opened food items were not labeled with a used by date. During a kitchen observation, a surveyor noted a rack of canned goods without expiration dates. When questioned, the Director of Dietary Services (DDS) and the Dietary Chef were unable to explain the process for discarding outdated canned goods, revealing that there was no system in place to track expiration or best by dates for these items. Additionally, an open box of Kellogg's Club Crackers was found without an expiration date, and neither the DDS nor the Dietary Chef could determine when it was opened or expired. In the dairy refrigerator, an open carton of heavy whipping cream was observed without a label indicating the date it was opened or its discard date. The Dietary Chef acknowledged that labeling dairy products with these dates was expected but had not been done in this instance.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as observed during a survey of 19 rooms on the Decker Unit. Over-the-door organizers were placed on the outside of resident room doors, containing various resident care items, including briefs. This arrangement was noted in rooms 406, 413, 416, 418, 419, 420, 421, 422, 424, 425, 426, 427, 428, 429, 430, 431, 432, 434, and 435. An interview with a resident revealed dissatisfaction and privacy concerns regarding the placement of these organizers. The resident expressed a lack of understanding as to why the organizers were positioned outside the room, indicating a failure to maintain the residents' dignity and respect.
Failure to Protect Resident's Medical Record Confidentiality
Penalty
Summary
The facility failed to ensure the confidentiality of a resident's medical record, as observed during a survey. On January 30, 2025, at 7:57 AM, a medication cart on the 400 hallway of the Decker Unit was found with a computer screen displaying a resident's name, date of birth, and Medication Administration Record (MAR). The medication cart was also unlocked, allowing access to several resident medications. At 8:00 AM, a Registered Nurse Supervisor (RN) approached the cart, closed the screen displaying the resident's information, and locked the cart. During an interview, the RN confirmed that the expectation was to close out of computer screens showing resident information and to lock the medication cart when unattended. She admitted that she was distracted by a resident need and failed to secure the cart and the computer screen.
Inaccurate MDS Assessments for Residents
Penalty
Summary
Facility staff failed to update the Minimum Data Set (MDS) assessments accurately for three residents, leading to deficiencies in reflecting their medical conditions. For Resident #8, the MDS did not indicate an unhealed stage 3 pressure ulcer by the Assessment Reference Date (ARD) of 01/15/25, despite documentation showing the wound was not fully healed. The MDS coordinator relied on staff documentation that inaccurately recorded the ulcer as healed, which was later corrected after the surveyor's inquiry. Resident #16's MDS with an ARD of 12/6/24 failed to reflect a pressure ulcer injury on the left first toe, despite medical records indicating the presence of such a wound. Similarly, Resident #31's MDS with an ARD of 1/13/25 did not document any wounds or skin conditions, even though medical records and observations showed multiple wounds on the resident's body. The MDS coordinator admitted that the assessments were based on progress notes and wound evaluations, which were not accurately reflected in the MDS.
Failure to Document and Monitor Resident's Skin Condition
Penalty
Summary
The facility failed to ensure that a resident received care based on professional standards, specifically in the area of skin condition monitoring. Resident #16 was observed to have a small bruise-like area on the left clavicle, which was not documented in the medical record. The Quality Assurance Nurse, who was assigned to the resident, was unaware of the skin condition until it was pointed out by the surveyor. Further investigation revealed that the facility had transitioned from paper to online documentation for weekly skin checks between November and December 2024, during which time Resident #16's weekly skin checks were missed, and no documentation was available to provide to the surveyor.
Oxygen Therapy Deficiency and Lack of Signage
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had orders that were being followed and failed to post cautionary signs indicating the use of oxygen. Specifically, Resident #31 was observed receiving oxygen at a rate of 3.5 to 4 liters per minute, despite having an active order for continuous oxygen at 3 liters per minute. Additionally, the nasal cannula used by Resident #31 was not changed as per the order, which required it to be replaced every Thursday night shift and labeled with the date. The nasal cannula was dated 1/17/25, indicating it had not been changed as required. Furthermore, the facility did not post cautionary signs indicating the use of oxygen for residents receiving oxygen therapy. During observations, it was noted that Resident #31's room did not have a red oxygen sign on the door, as expected by the Director of Nursing (DON). Similarly, Resident #9, who was also receiving oxygen by nasal cannula, did not have a sign on the door indicating the use of oxygen. These deficiencies were confirmed through interviews with the DON and observations made by the surveyor.
Failure to Obtain Informed Consent and Document Alternatives for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent and document alternatives attempted prior to the initiation of bed rails for two residents. During the survey, it was observed that both residents had bed rails installed without proper documentation of informed consent or assessment of alternatives. Resident #31 was observed with two 1/4 bed rails on either side of the bed, and the Director of Rehabilitation was unable to provide a reason for their use, as the resident was not on the case load. Similarly, Resident #13's bed was observed with two 1/4 bed rails, and the Director of Nursing mentioned that verbal consent was obtained but could not provide documentation. The surveyor requested documentation for both residents regarding the assessment of alternatives and informed consent, but the Director of Nursing was unable to provide this information. The lack of documentation and informed consent indicates a failure in the facility's process for ensuring the safe and appropriate use of bed rails, which are associated with potential risks. This deficiency was identified during the survey, highlighting the facility's non-compliance with the required procedures for bed rail use.
Failure to Conduct Annual Performance Reviews for GNAs
Penalty
Summary
The facility failed to ensure that staff received annual performance reviews, as evidenced by the lack of documentation for four GNAs during the annual survey. On January 30, 2024, the surveyor requested documentation of annual performance reviews for the years 2023 and 2024 for GNA #7, GNA #19, GNA #21, and GNA #26. However, during an interview on January 31, 2025, the Director of Nursing revealed that the facility was unable to provide the requested documentation, indicating non-compliance with the requirement for annual performance reviews for these GNAs.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility was found to have a medication error rate of 11.54%, exceeding the acceptable threshold of less than 5%. This was identified during a surveyor's observation of medication administration for three residents. For Resident #236, a discrepancy was noted when the RN Supervisor documented the administration of five medications, including Bicalutamide 50MG, which was not observed to be prepared or administered. A subsequent audit and pill count confirmed that the medication had not been given as documented, as there were 26 pills remaining in the bottle, indicating a missed dose since the bottle was opened. Additionally, errors were observed in the administration of medications to Resident #9 and Resident #16. Resident #9 received two drops of Ophthalmic solution 0.5% carboxymethylcellulose in each eye, contrary to the order for one drop per eye. Similarly, Resident #16 was administered OcuSoft Lid Scrub to both eyes, while the order specified application only to the left eye. These observations were reviewed with the Director of Nursing, who acknowledged the discrepancies in medication administration.
Significant Medication Error in Resident's Treatment
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, as observed during a survey. On the morning of January 30, 2025, a surveyor observed a Registered Nurse Supervisor administer four medications to a resident. However, the documentation later showed that five medications were signed off as administered, including Bicalutamide 50MG, which was not observed to be prepared or given to the resident. This discrepancy was confirmed through a review of the Medication Administration Record (MAR) and an audit conducted by the surveyor. Further investigation revealed that the Bicalutamide medication bottle, which initially contained 30 pills, had a date of January 27, 2025, indicating when it was first opened. A pill count conducted on January 31, 2025, showed 26 pills remaining, suggesting that only four pills had been administered since the bottle was opened. This count was inconsistent with the expected number of pills if the medication had been administered daily as prescribed. The Director of Nursing (DON) confirmed the significant medication error, acknowledging that the number of pills remaining did not align with the administration records.
Failure to Conduct Regular Bedrail Entrapment Assessments
Penalty
Summary
The facility failed to conduct regular inspections of bed frames, mattresses, and bed rails to identify potential areas of entrapment, as evidenced by observations and staff interviews. During the survey, it was observed that two residents had 1/4 bed rails raised on either side of the top end of their beds. The Director of Maintenance admitted that there was no documentation available for routine bedrail entrapment assessments for these residents. Although maintenance staff conducted routine checks of resident rooms, these checks did not include assessments for the risk of entrapment for residents with transfer bars or bed rails.
Non-Compliance with GNA In-Service Training Requirements
Penalty
Summary
The facility failed to ensure that Geriatric Nursing Assistants (GNAs) completed the required 12 hours of in-service training annually. This deficiency was identified during a survey where the records of five GNAs were reviewed. Specifically, GNA #7 received only 3 hours, GNA #19 received 5 hours, and GNA #21 received no in-service training in 2024. An interview with the Director of Nursing confirmed the facility's non-compliance with the annual training requirement for these staff members.
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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 Towson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Chestnut Grn Hlth Ctr Blakehur | 0.3 mi | ★★★★★ | 13 | 0 |
| Autumn Lake Healthcare At Ruxton | 0.5 mi | ★★★★★ | 43 | 0 |
| Orchard Hill Rehabilitation And Healthcare Center | 0.6 mi | ★★★★★ | 42 | 0 |
| Greater Baltimore Medical Center Sub Acute Unit | 0.8 mi | — | 0 | 0 |
| Edenwald | 1.3 mi | ★★★★★ | 3 | 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.