Cycle 1
Health 2024-06-03 · Fire 2024-06-03
29 health deficiencies
Top issue: Quality of Life and Care (7 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Forestville, MD
Forestville Healthcare Center
3-star overall rating with 2-star inspections with $16,039 in total fines with 29 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
7420 Marlboro Pike, Forestville, MD
(301) 736-0240
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
162
Certified beds
Average residents
153
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Communicare Health
Operator or chain grouping
Approved since
1971-02-20
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing
LPN hours / resident day
1.00
Licensed practical nurse staffing
Aide hours / resident day
1.95
Nurse aide staffing
Weekend hours
3.04
Weekend nurse staffing
RN turnover
43%
Annual RN turnover
Total nurse turnover
34%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.8 |
1.3
0.5 pts better
|
1.9
1.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.6 |
1.2
0.6 pts better
|
1.8
1.2 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.3% |
91.9%
1.4 pts better
|
93.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
96.6%
0.6 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.2% |
2.3%
2.1 pts better
|
3.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
21.4%
16.8 pts better
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.6% |
5.7%
0.9 pts worse
|
5.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.2% |
16.1%
0.9 pts better
|
19.6%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 11.5% |
15.3%
3.8 pts better
|
16.7%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 19.9% |
26.6%
6.7 pts better
|
16.3%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
22.9%
7.1 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.7%
0.7 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
1.5%
1.1 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
25.4%
1.1 pts better
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.4% |
6.3%
0.1 pts worse
|
5.1%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 63.5% |
78.4%
14.9 pts worse
|
81.7%
18.2 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
9.9%
4.5 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
80.6%
4.4 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 32.6% |
21.2%
11.4 pts worse
|
23.9%
8.7 pts worse
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-06-24 · Fire 2019-06-24
9 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2018-03-14 · Fire 2018-03-14
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-06-03
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 2024-08-12
F · Potential for more than minimal harm
2024-06-03
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-06-03
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-12
F · Potential for more than minimal harm
2024-06-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-06-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-03
F · Potential for more than minimal harm
2024-06-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-03
K253 · Egress Deficiencies
Fire Safety
Provide two separate exits in rooms of more than 1000 square feet.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-03
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-08-12
E · Potential for more than minimal harm
2024-06-03
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2024-08-12
D · Potential for more than minimal harm
2019-06-24
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 2019-08-30
D · Potential for more than minimal harm
2019-06-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2019-08-30
F · Potential for more than minimal harm
2018-03-14
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-04-21
D · Potential for more than minimal harm
2018-03-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2018-04-21
D · Potential for more than minimal harm
2018-03-14
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2018-04-21
Inspection history
Recent health citations
D · Potential for more than minimal harm
2026-01-12
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
D · Potential for more than minimal harm
2026-01-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
D · Potential for more than minimal harm
2026-01-12
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.
Not marked corrected
D · Potential for more than minimal harm
2025-11-06
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-11-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-19
D · Potential for more than minimal harm
2025-11-06
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 2025-12-19
D · Potential for more than minimal harm
2025-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-19
G · Actual harm
2024-06-03
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-03
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 2024-07-18
E · Potential for more than minimal harm
2024-06-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-18
E · Potential for more than minimal harm
2024-06-03
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 2024-08-27
D · Potential for more than minimal harm
2024-06-03
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 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
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 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
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 2024-08-27
D · Potential for more than minimal harm
2024-06-03
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-06-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
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 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
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 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-06-03
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
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 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-27
D · Potential for more than minimal harm
2024-06-03
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-07-18
D · Potential for more than minimal harm
2024-06-03
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-07-18
E · Potential for more than minimal harm
2019-06-24
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 2019-08-08
E · Potential for more than minimal harm
2019-06-24
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-08-08
D · Potential for more than minimal harm
2019-06-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2019-08-08
D · Potential for more than minimal harm
2019-06-24
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 2019-08-08
D · Potential for more than minimal harm
2019-06-24
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 2019-08-08
D · Potential for more than minimal harm
2019-06-24
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-08-08
D · Potential for more than minimal harm
2019-06-24
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2019-08-08
D · Potential for more than minimal harm
2019-06-24
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 2019-08-08
E · Potential for more than minimal harm
2018-03-14
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2018-04-18
E · Potential for more than minimal harm
2018-03-14
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2018-04-18
D · Potential for more than minimal harm
2018-03-14
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 2018-04-18
D · Potential for more than minimal harm
2018-03-14
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 2018-04-18
D · Potential for more than minimal harm
2018-03-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2018-04-18
D · Potential for more than minimal harm
2018-03-14
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 2018-04-18
D · Potential for more than minimal harm
2018-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2018-04-18
D · Potential for more than minimal harm
2018-03-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2018-04-18
B · Minimal harm
2018-03-14
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 2018-04-18
Penalties and ownership
What sits behind the stars
$16,039
2024-06-03
Fine
Fine · fine $16,039
Fine
Ownership
Omg Re Leasing Co, LLC
5% Or Greater Direct Ownership Interest · Organization
C R Stoltz Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
C.r. Stoltz Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Dave, Mitul
Operational/Managerial Control · Individual
Groves, Donna
Operational/Managerial Control · Individual
Harris, James
Operational/Managerial Control · Individual
Hc Real Estate Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
I. Rosedale Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Marlboro Mgmt Co, LLC
Operational/Managerial Control · Organization
Ohi Asset (Md) Forestville, LLC
5% Or Greater Security Interest · Organization
Omg Re Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
R.s. Wilheim Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Romeo, Dominic
Operational/Managerial Control · Individual
Romeo, Dominic
Corporate Officer · Individual
Ronald S Wilheim 2012 Spousal Trust
5% Or Greater Indirect Ownership Interest · Organization
Rosedale Family Investment Company, Inc
5% Or Greater Indirect Ownership Interest · Organization
Rrw, LLC
5% Or Greater Indirect Ownership Interest · Organization
S.l. Rosedale Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Stoltz, Charles
Corporate Officer · Individual
Wilheim Family Investment Company, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Wilheim, Ronald
Corporate Officer · Individual
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#3
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