Lexington Park, MD

Chesapeake Shores Nursing Center

3-star overall rating with 3-star inspections with $47,254 in total fines with 25 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

21412 Great Mills Road, Lexington Park, MD

(301) 863-7244

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

125

Certified beds

Average residents

90

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1982-09-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.58

Registered nurse staffing · state 0.81 · national 0.68

LPN hours / resident day

0.78

Licensed practical nurse staffing · state 0.91 · national 0.87

Aide hours / resident day

2.30

Nurse aide staffing · state 2.15 · national 2.35

Total nurse hours

3.66

All reported nurse hours · state 3.87 · national 3.89

Licensed hours

1.36

RN + LPN hours · state 1.72 · national 1.54

Weekend hours

3.31

Weekend nurse staffing · state 3.46 · national 3.43

Weekend RN hours

0.48

Weekend registered nurse coverage · state 0.61 · national 0.47

Physical therapist

0.06

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.58

CMS adjusted RN staffing hours

Adjusted total hours

3.61

CMS adjusted total nurse staffing hours

Case-mix index

1.39

Higher values indicate more complex resident acuity

RN turnover

47%

Annual RN turnover · state 40% · national 45%

Total nurse turnover

47%

Annual nurse turnover · state 41% · national 46%

SNF VBP

Value-based purchasing

Program rank

10,865

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

18.84

Composite VBP score used to determine payment impact.

Payment multiplier

0.9820

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

0

Baseline 21.73% · Performance 21.76% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

2.88

Baseline 7.01% · Performance 6.98% · Measure score 2.88 · Achievement 2.88 · Improvement 0

Total nurse turnover

3.09

Baseline 55.10% · Performance 51.04% · Measure score 3.09 · Achievement 3.09 · Improvement 0.84

Adjusted total nurse staffing

1.57

Baseline 3.34 hours · Performance 3.52 hours · Measure score 1.57 · Achievement 1.57 · Improvement 0.26

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 13.64%
10.72%
2.9 pts worse
Worse than the National Rate · Eligible stays 256 · Observed rate 17.97% · Lower 95% interval 10.89%
Discharge to community 55.08%
50.57%
4.5 pts better
No Different than the National Rate · Eligible stays 224 · Observed rate 46.43% · Lower 95% interval 48.93%
Medicare spending per beneficiary 0.97
1.02
0.1 pts better
Drug regimen review with follow-up 96.99%
95.27%
1.7 pts better
Numerator 129 · Denominator 133
Falls with major injury 1.5%
0.77%
0.7 pts worse
Numerator 2 · Denominator 133
Discharge self-care score 35.44%
53.69%
18.2 pts worse
Numerator 28 · Denominator 79
Discharge mobility score 43.04%
50.94%
7.9 pts worse
Numerator 34 · Denominator 79
Pressure ulcers or injuries, new or worsened 6.77%
2.29%
4.5 pts worse
Numerator 9 · Denominator 133 · Adjusted rate 6.15%
Healthcare-associated infections requiring hospitalization 6.97%
7.12%
0.2 pts better
No Different than the National Rate · Eligible stays 150 · Observed rate 8% · Lower 95% interval 4.43%
Staff COVID-19 vaccination coverage 1.87%
8.2%
6.3 pts worse
Numerator 2 · Denominator 107
Staff flu vaccination coverage 92.92%
42%
50.9 pts better
Numerator 105 · Denominator 113
Discharge function score 45.57%
56.45%
10.9 pts worse
Numerator 36 · Denominator 79
Transfer of health information to provider 90.2%
95.95%
5.8 pts worse
Numerator 46 · Denominator 51
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 53 · Denominator 53
Resident COVID-19 vaccinations up to date 63.27%
25.2%
38.1 pts better
Numerator 31 · Denominator 49

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 1.0
1.3
0.3 pts better
1.9
0.9 pts better
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.7 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 2.2
1.2
1 pts worse
1.8
0.4 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.1 · Expected 1.6 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 98.8%
91.9%
6.9 pts better
93.4%
5.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 98.8% · Q3 98.8% · Q4 98.8% · 4Q avg 98.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100.0%
96.6%
3.4 pts better
95.5%
4.5 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury 4.3%
2.3%
2 pts worse
3.3%
1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 2.5% · Q3 4.8% · Q4 6.0% · 4Q avg 4.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 18.6%
21.4%
2.8 pts better
11.4%
7.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 16.4% · Q2 21.3% · Q3 22.4% · Q4 14.3% · 4Q avg 18.6%
Percentage of long-stay residents who lose too much weight 8.7%
5.7%
3 pts worse
5.4%
3.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 10.4% · Q3 8.9% · Q4 8.6% · 4Q avg 8.7%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 16.0%
16.1%
0.1 pts better
19.6%
3.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 16.5% · Q3 17.1% · Q4 14.5% · 4Q avg 16.0%
Percentage of long-stay residents who received an antipsychotic medication 12.6%
15.3%
2.7 pts better
16.7%
4.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 15.3% · Q3 9.7% · Q4 11.1% · 4Q avg 12.6% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.0%
About the same
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 30.7%
26.6%
4.1 pts worse
16.3%
14.4 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 30.7% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 16.2%
22.9%
6.7 pts better
14.9%
1.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 13.9% · Q2 20.0% · Q3 18.2% · Q4 12.7% · 4Q avg 16.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.1%
0.7%
0.4 pts worse
1.0%
0.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.2% · Q3 0.8% · Q4 0.6% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 2.8%
1.5%
1.3 pts worse
1.7%
1.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.5% · Q3 0.0% · Q4 6.1% · 4Q avg 2.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 15.4%
25.4%
10 pts better
19.8%
4.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 18.5% · Q3 20.0% · Q4 11.4% · 4Q avg 15.4%
Percentage of long-stay residents with pressure ulcers 11.6%
6.3%
5.3 pts worse
5.1%
6.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 13.7% · Q3 14.2% · Q4 9.1% · 4Q avg 11.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 91.9%
78.4%
13.5 pts better
81.7%
10.2 pts better
Short Stay · 2024Q4-2025Q3 · Q1 94.8% · Q2 94.4% · Q3 88.2% · Q4 88.7% · 4Q avg 91.9%
Percentage of short-stay residents who had an outpatient emergency department visit 20.7%
9.9%
10.8 pts worse
12.0%
8.7 pts worse
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 20.6% · Expected 11.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.4%
1.3%
0.1 pts worse
1.6%
0.2 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.9% · Q3 2.1% · Q4 2.3% · 4Q avg 1.4% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 100.0%
80.6%
19.4 pts better
79.7%
20.3 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 32.7%
21.2%
11.5 pts worse
23.9%
8.8 pts worse
Short Stay · 20240701-20250630 · Adjusted 32.7% · Observed 34.3% · Expected 25.0% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-05-15 · Fire 2024-05-15

25 health deficiencies

Top issue: Quality of Life and Care (5 deficiencies)

8 fire-safety deficiencies

Top issue: Egress (2 deficiencies)

Cycle 2 Health 2019-05-17 · Fire 2019-05-17

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Cycle 3 Health 2018-01-12 · Fire 2018-01-12

5 health deficiencies

Top issue: Administration (1 deficiency)

4 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-05-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-07-03

F · Potential for more than minimal harm 2024-05-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-07-03

F · Potential for more than minimal harm 2024-05-15

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2024-07-03

F · Potential for more than minimal harm 2024-05-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-05-15

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-07-03

E · Potential for more than minimal harm 2024-05-15

K223 · Egress Deficiencies

Fire Safety

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Corrected 2024-07-03

D · Potential for more than minimal harm 2024-05-15

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2024-07-03

D · Potential for more than minimal harm 2024-05-15

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-07-03

D · Potential for more than minimal harm 2019-05-17

K100 · Construction Deficiencies

Fire Safety

Meet other general requirements.

Corrected 2019-05-31

D · Potential for more than minimal harm 2019-05-17

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-05-31

D · Potential for more than minimal harm 2019-05-17

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2019-05-31

D · Potential for more than minimal harm 2019-05-17

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-05-31

D · Potential for more than minimal harm 2019-05-17

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2019-05-31

F · Potential for more than minimal harm 2018-01-12

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2018-03-25

D · Potential for more than minimal harm 2018-01-12

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2018-03-25

D · Potential for more than minimal harm 2018-01-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2018-03-25

D · Potential for more than minimal harm 2018-01-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2018-03-25

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-05-15

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2024-06-18

F · Potential for more than minimal harm 2024-05-15

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2024-06-18

F · Potential for more than minimal harm 2024-05-15

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2024-06-18

E · Potential for more than minimal harm 2024-05-15

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2024-06-18

E · Potential for more than minimal harm 2024-05-15

F697 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate pain management for a resident who requires such services.

Corrected 2024-06-18

E · Potential for more than minimal harm 2024-05-15

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F624 · Resident Rights Deficiencies

Health

Prepare residents for a safe transfer or discharge from the nursing home.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F655 · Resident Assessment and Care Planning Deficiencies

Health

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F730 · Nursing and Physician Services Deficiencies

Health

Observe each nurse aide's job performance and give regular training.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F740 · Quality of Life and Care Deficiencies

Health

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F883 · Infection Control Deficiencies

Health

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Corrected 2024-06-18

D · Potential for more than minimal harm 2024-05-15

F909 · Environmental Deficiencies

Health

Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.

Corrected 2024-06-18

E · Potential for more than minimal harm 2019-05-17

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2019-07-03

E · Potential for more than minimal harm 2019-05-17

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-07-03

D · Potential for more than minimal harm 2019-05-17

F622 · Resident Rights Deficiencies

Health

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Corrected 2019-07-03

D · Potential for more than minimal harm 2019-05-17

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2019-07-03

D · Potential for more than minimal harm 2018-01-12

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2018-02-02

D · Potential for more than minimal harm 2018-01-12

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2018-02-02

D · Potential for more than minimal harm 2018-01-12

F711 · Nursing and Physician Services Deficiencies

Health

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Corrected 2018-02-02

D · Potential for more than minimal harm 2018-01-12

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2018-02-02

B · Minimal harm 2018-01-12

F846 · Administration Deficiencies

Health

Have policies and procedures ensuring the administrator's responsibilities for facility closure are completed successfully.

Corrected 2018-02-02

Penalties and ownership

What sits behind the stars

$47,254 2024-05-15

Fine

Fine · fine $47,254

Fine

Ownership

Karim, Shahana

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-01
Mayer, Moishe

Operational/Managerial Control · Individual

0% 2 facilities 2022-11-01
Veneziani, Courtney

Operational/Managerial Control · Individual

0% 1 facilities 2025-01-01

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