PICKERSGILL RETIREMENT COMMUNITY

615 CHESTNUT AVENUE, TOWSON, MD 21204 (410) 825-7423
For profit - Corporation 43 Beds Independent Data: November 2025
Trust Grade
65/100
#122 of 219 in MD
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Last Inspection: January 2025

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Picker'sgill Retirement Community has a Trust Grade of C+, which indicates that it is slightly above average but not outstanding. It ranks #122 out of 219 facilities in Maryland, placing it in the bottom half, and #24 out of 43 in Baltimore County, indicating there are only a few local options that are better. Unfortunately, the facility is worsening, with reported issues increasing from 4 in 2020 to 12 in 2025. Staffing is a relative strength, with a 4 out of 5-star rating and RN coverage that exceeds 91% of Maryland facilities, though the turnover rate is high at 54%, above the state average. While there have been no fines, the facility has received concerning feedback, such as failing to label food properly, which could impact residents, and not ensuring resident dignity, as evidenced by care items being displayed outside rooms, raising privacy concerns.

Trust Score
C+
65/100
In Maryland
#122/219
Bottom 45%
Safety Record
Low Risk
No red flags
Inspections
Getting Worse
4 → 12 violations
Staff Stability
⚠ Watch
54% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties
✓ Good
No fines on record. Clean compliance history, better than most Maryland facilities.
Skilled Nurses
✓ Good
Each resident gets 79 minutes of Registered Nurse (RN) attention daily — more than 97% of Maryland nursing homes. RNs are the most trained staff who catch health problems before they become serious.
Violations
⚠ Watch
19 deficiencies on record. Higher than average. Multiple issues found across inspections.
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★☆☆☆☆
1.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2020: 4 issues
2025: 12 issues

The Good

  • 4-Star Staffing Rating · Above-average nurse staffing levels
  • Full Sprinkler Coverage · Fire safety systems throughout facility
  • No fines on record

Facility shows strength in staffing levels, fire safety.

The Bad

3-Star Overall Rating

Near Maryland average (3.0)

Meets federal standards, typical of most facilities

Staff Turnover: 54%

Near Maryland avg (46%)

Higher turnover may affect care consistency

The Ugly 19 deficiencies on record

Jan 2025 12 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0583 (Tag F0583)

Could have caused harm · This affected 1 resident

Based on observation and interview, it was determined that the facility failed to ensure a resident's medical record was protected from public view. This was evident for 1 of 2 medication carts (400 h...

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Based on observation and interview, it was determined that the facility failed to ensure a resident's medical record was protected from public view. This was evident for 1 of 2 medication carts (400 hallway medication cart) observed during the survey. The findings include: On 01/30/25 at 07:57 AM, an observation on the Decker Unit revealed a medication cart on the 400 hallway which revealed a computer screen open with Resident #21's name, date of birth , and Medication Administration Record (MAR). The same medication cart which the computer was on was unlocked, which would allow anyone to open medication cart drawers with several resident medications inside. On 01/30/25 at 08:00 AM, an observation revealed Registered Nurse Supervisor (RN #22) walked up to the medication cart and closed out of the screen which was revealing Resident #21's information and locked the cart. The surveyor approached RN #22 and asked if she was assigned to the medication cart at the time, she indicated yes. On 01/30/25 at 8:00 AM, an interview with RN #22 revealed that the expectation was for nurses to close out of computer screens which reveal resident information and to lock the medication cart whenever they walked away from it. She further indicated that she was pulled away for a resident need and did not lock the cart or close out of the resident revealing computer screen.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Based on record reviews and interviews, it was determined that facility staff failed to update the residents' (#8) Minimum Data Set to accurately reflect the resident's medical condition, and failed t...

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Based on record reviews and interviews, it was determined that facility staff failed to update the residents' (#8) Minimum Data Set to accurately reflect the resident's medical condition, and failed to code the residents' (#16, #31) status accurately on the Minimum Data Set (MDS) assessment. This occurred for 3 (#8, #16, #31) out of 3 residents reviewed during the annual survey. The findings include: The Minimum Data Set (MDS) is a federally mandated assessment tool that helps nursing home staff gather information on each resident's strengths and needs. The information collected drives resident care planning decisions. MDS assessments need to be accurate to ensure each resident receives the care they need. The Assessment Reference Date (ARD) is the specific end point of look-back periods of resident status for the MDS assessment process. 1) On 01/31/25 at 7:38 AM, a review of Resident #8's treatment administration record for December 2024 revealed an order to apply Optifoam (foam wound dressing) pad to sacrum topically every day. The treatment order start date was 12/03/2024 at 7:00 AM, and discontinue date was 01/30/2025 5:20PM. On 01/31/25 at 9:07 AM, the surveyor reviewed a wound evaluation note dated 12/31/24 for Resident #8. The evaluation indicated an MDS 3.0 stage 3 wound, and the provider noted wound progress. Review of Resident #8's MDS under the skin condition section on 01/31/25 at 8:42 AM, failed to indicate an unhealed stage 3 pressure ulcer. The assessment reference date (MDS completion) was 01/15/25. On 01/31/25 at 10:10 AM, during an interview with MDS coordinator #14, when asked why a stage 3 pressure ulcer was not captured in the MDS by the ARD of 01/15/25. The MDS coordinator #14 explained that updates to the MDS are based on staff documentation and that Resident #8's pressure ulcer had been documented as healed. The surveyor requested documentation confirming that the pressure ulcer was recorded as healed. On 01/31/25 at 11:14 AM, during an interview with Nurse Unit Manager (UM) #5 the surveyor inquired about the status of Resident#8's pressure ulcer. The UM #5 explained that the wound initially started as a stage 2 pressure ulcer, progressed to stage 3, and was currently healing. The surveyor asked if the pressure ulcer was fully healed, the UM #5 responded, It isn't healed. On 01/31/25 at 11:32 AM, review of wound care progress note dated on 01/14/25 by the physician revealed, Signing off on patient who remains in the facility. Per nursing, the wound continues to heal. Please reconsult if the wound worsens. On 01/31/25 at 12:11 PM, the Director of Nursing (DON) #2 provided the surveyor with a copy of an amended MDS reflecting a correction was made on 01/31/25 in the skin condition section to indicate a pressure ulcer. The DON #2 acknowledged that the pressure ulcer had not been documented in the MDS by the ARD of 01/15/25. 2) On 01/30/25 at 10:21 AM, review of Resident #16's medical record revealed a progress note dated 12/03/25 at 4:40 PM, which indicated the resident had been seen by the wound doctor that day for a left first toe wound. On 01/30/25 at 10:24 AM, review of Resident #16's medical record revealed an assessment titled, Wound Evaluation and Management Summary, dated 12/3/24 which indicated the resident had a wound on his/her left first toe. On 01/30/25 at 10:27 AM, review of section M (skin conditions) of Resident #16's most recent MDS with an ARD of 12/6/24 failed to reveal indication that the resident had a pressure ulcer injury. On 01/31/25 at 10:10 AM, an interview with the Director of Nursing (DON, Staff #2) revealed that Resident #16's toe injury was a pressure ulcer and should have been coded on the MDS with an ARD date of 12/6/24. 3) On 01/29/25 at 08:14 AM, an initial observation of Resident #31 revealed that he/she had an air mattress. An air mattress can eliminate pressure sores and ulcers from forming and existing sores from worsening. On 01/30/25 at 02:33 PM, review of Resident #31's medical record revealed a progress note dated 1/9/25 at 03:14 AM, which indicated that the resident's wound dressing was intact and right heel dressing applied. On 01/30/25 at 02:34 PM, further review of Resident #31's medical record revealed a progress note dated 1/11/25 at 03:32 AM, which indicated there was a new cream medication ordered for multiple skin issues on trunk and arms. On 01/30/25 at 02:36 PM, further review of Resident #31's medical record revealed an assessment titled, Wound Evaluation and Management Summary dated 1/7/25 which indicated the resident had wounds on his/her right lower leg, right upper calf, and right heel. On 01/30/25 at 02:27 PM, an interview with the MDS Coordinator (Staff #14) revealed that staff rely on progress notes and wound assessments to complete section M of the MDS. On 01/30/25 at 02:37 PM, review of section M (skin conditions) of Resident #31's recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/13/25 failed to reveal any indication that the resident had any wounds or skin conditions.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on record review and staff interview, the facility failed to ensure a resident received care based on professional standards. This was evident for 1 (Resident #16) of 2 residents reviewed for sk...

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Based on record review and staff interview, the facility failed to ensure a resident received care based on professional standards. This was evident for 1 (Resident #16) of 2 residents reviewed for skin conditions. The findings include: On 01/29/25 at 08:18 AM, an initial observation of Resident #16 revealed a small bruise-like area on the his/her left clavicle. On 01/30/25 at 10:21 AM, review of Resident #16's medical record failed to reveal documentation indicating the skin condition was identified. On 01/30/25 12:17 PM, an interview with the Quality Assurance Nurse (Staff #20) revealed that she was assigned to Resident #16. She indicated she was not aware of Resident #16's current skin conditions. The surveyor and Staff #20 walked to the residents room and the surveyor pointed out the area of concern on his/her left clavicle. Staff #20 said that the resident has ecchymosis. On 01/30/25 at 12:20 PM, the surveyor requested documentation of Resident #16's weekly skin checks from Staff #20. On 01/30/25 at 12:27 PM, an interview with the Unit Manager (Staff #5) revealed that the facility switched over from paper to online weekly skin checks between November and December of 2024, that they had missed Resident #16's weekly skin checks since, and have none since to provide.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Respiratory Care (Tag F0695)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with facility staff, it was determined that the facility failed to ensure that a resident rec...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview with facility staff, it was determined that 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. This was evident for 1 (Resident #31) of 1 resident reviewed for respiratory care, and 1 (Resident #9 and #31) of 2 residents observed receiving oxygen. The findings include: 1) On 01/29/25 at 08:14 AM, an initial observation of Resident #31 revealed she/he was on oxygen by nasal cannula. The oxygen level was at 3.5 liters/minute. The nasal cannula was dated 1/27/25. A nasal cannula is a small, flexible tube that fits inside both nostrils, delivering supplemental oxygen directly into your nose. Oxygen liter refers to the amount of oxygen a person receives per minute, measured in liters, and is essentially how much supplemental oxygen is being delivered to them through a piece of oxygen supplying equipment. On 01/29/25 at 02:33 PM, review of Resident #31's medical record revealed an active order dated 1/6/25 which indicated continuous oxygen at 3 liters by nasal cannula. On 01/29/25 at 02:33 PM, further review of Resident #31's medical record revealed an active order dated 1/6/25 which indicated to change the oxygen tubing/nasal cannula tubing every Thursday night shift and to label with the date. On 01/30/25 at 07:12 AM, a second observation of Resident #31 revealed he/she was still on oxygen by nasal cannula, at a rate of 3.5- 4 liters/minute. The nasal cannula was dated 1/17/25. On 01/30/25 at 07:25 AM, an interview with the Director of Nursing (DON, Staff #2) revealed the expectation for residents on oxygen is for the orders to be followed by staff and if the level of oxygen needs to be increased or decreased, that staff should reach out to the provider. On 01/30/25 at 07:28 AM, the surveyor and the DON went to Resident #31's room. The DON read the oxygen level on Resident #31's oxygen supplying equipment and indicated it was at 4 liters/minute. The surveyor also reviewed the concern regarding the tubing dated 1/17/25. 2a) On 01/30/25 at 07:28 AM, an observation with the DON of Resident #31 in his/her room revealed he/she was on oxygen. When the surveyor asked what the expectation was for signage when a resident is on oxygen, she indicated that there would be a red oxygen sign on the resident's door. She indicated that there failed to be one on Resident #31's door, and that she would go and get one. 2b) On 01/30/25 at 12:18 PM, an observation on Decker Unit revealed Resident #9, in room [ROOM NUMBER], who was actively receiving oxygen by nasal cannula, but failed to reveal a sign on the resident's door indicating the use of oxygen. On 01/31/25 at 10:10 AM, the surveyor reviewed the concern with the DON regarding the failure to ensure cautionary signage was posted for Resident #9 and #31.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0700 (Tag F0700)

Could have caused harm · This affected 1 resident

Based on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent and document alternatives attempted prior to the initiation...

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Based on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent and document alternatives attempted prior to the initiation of bed rails. This was evident for 2 (Resident #31 and #13) of 2 residents reviewed for accident hazards. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. The facility should obtain a signed consent form before the use of bedrails. 1) On 01/29/25 at 08:14 AM, during the initial phase of the survey, the surveyor observed Resident #31 in bed with two 1/4 bed rails up on either side of the top end of the bed. On 01/30/25 at 09:37 AM, an interview with the Director of Rehabilitation (Staff #16), revealed that Resident #31 was from assisted living and had not been on case load and was unable to indicate why the resident had the transfer bars/bed rails. 2) On 01/29/25 at 10:05 AM, during the initial phase of the survey, the surveyor observed Resident #13's bed in his/her room which revealed two 1/4 bed rails up on either side of the top end of the bed. On 01/30/25 at 07:23 AM, an interview with the Director of Nursing (DON, Staff #2) revealed that verbal consent is obtained for transfer bars/ bed rails, but would double check for documentation. On 01/30/25 at 09:37 AM, an interview with the Director of Rehabilitation (Staff #16), revealed that therapy will assess resident ability and determine whether transfer bars are necessary. The surveyor requested documentation for Resident #13 and #31 of alternatives attempted and the initial assessments completed for the transfer bars/ bed rails. On 01/30/25 at 11:09 AM, the DON indicated to the surveyor that she was unable to provide documentation of alternatives attempted and consent for Resident #13 and #31's prior to initiation of transfer bars/bed rails.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0730 (Tag F0730)

Could have caused harm · This affected 1 resident

Based on interview, it was determined that the facility failed to ensure staff received annual performance reviews. This was evident for 4 of 5 GNAs (GNA#7, GNA #19, GNA #21, and GNA #26) reviewed dur...

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Based on interview, it was determined that the facility failed to ensure staff received annual performance reviews. This was evident for 4 of 5 GNAs (GNA#7, GNA #19, GNA #21, and GNA #26) reviewed during the annual survey. The findings include: On 01/30/24 at 4:00 PM, the surveyor requested documentation of annual performance reviews for the last two years (2023 and 2024) for GNA #7, GNA #19, GNA #21, and GNA #26. On 01/31/25 at 10:10 AM, an interview with the Director of Nursing (DON) revealed that the facility was unable to provide the documentation requested by the surveyor because the facility was not in compliance with annual performance reviews for GNA #7, GNA #19, GNA #21, and GNA #26.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Unnecessary Medications (Tag F0759)

Could have caused harm · This affected 1 resident

Based on observation, record review, and interview, it was determined that the facility failed to have a medication error rate of less than 5% during medication administration observation. This was ev...

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Based on observation, record review, and interview, it was determined that the facility failed to have a medication error rate of less than 5% during medication administration observation. This was evident for 3 (Resident #9, #16, and #236) of 26 medication administration opportunities which resulted in a medication error rate of 11.54%. The findings include: 1) On 01/30/25 at 08:02 AM, the surveyor observed Registered Nurse (RN) Supervisor #22 administer 4 medications to Resident #236. On 01/30/25 at 08:15 AM, the surveyor observed RN #22 document the medications, which revealed 5 medications being signed off as administered, which included Bicalutamide 50MG, which was not observed to be prepared or administered to Resident #236. On 01/30/25 at 08:26 AM, review of Resident #236 Medication Administration Record (MAR) revealed 5 medications signed off, including Bicalutamide Tablet 50 MG (A drug used with another drug to treat prostate cancer that has spread to other parts of the body). On 01/31/25 at 12:52 PM, the surveyor obtained a MAR audit for Resident #236, which revealed the exact time that the medication was signed off, which indicated 01/30/25 at 08:16 AM. On 01/31/25 at 12:53 PM, the surveyor reviewed the concern with the DON regarding Resident #236 's medication administration observation and MAR audit review. On 01/31/25 at 12:57 PM, the DON completed a pill count of the Bicalutamide medication with the Unit Manager/Staff #5 and the surveyor present. There were 26 pills counted to be in the bottle. On 01/31/25 at 12:58 PM, the surveyor observed a date of 1/27/25 on the pill bottle (which indicated the first date of which a pill was taken out the bottle). On 01/31/25 at 12:58 PM, an interview with the DON who was present during the observation revealed that the date written in would be the date a staff member opened the bottle. On 01/31/25 at 12:59 PM, the surveyor obtained the medication bottle of Bicalutamide, which indicated a quantity of 30 pills were in the bottle prior to being opened. On 01/31/25 at 01:07 PM, an interview with the DON revealed that if medication had been given each day since the bottle was opened on 1/27/25, then there would be a total of 25 pills left in the bottle at the time of the pill count. She was in agreement with the medication error finding. 2) On 01/31/25 at 07:20 AM, the surveyor observed Registered Nurse (Staff #23) administer Ophthalmic solution 0.5% carboxymethylcellulose, 2 drops into each of Resident #9's eyes (right and left). On 01/31/25 at 08:02 AM, review of Resident #9's order for Ophthalmic solution 0.5% carboxymethylcellulose revealed, 1 drop into each of Resident #9's eyes (right and left). 3) On 01/31/25 at 07:33 AM, the surveyor observed Staff #23 administer OcuSoft Lid Scrub to Resident #16's left and right eye. On 01/31/25 at 07:59 AM, the surveyor reviewed the MAR for Resident #16 which revealed an order for OcuSoft Scrub to the left eye, which was signed off for the 8:00 AM administration. On 01/31/25 at 12:53 PM, the surveyor reviewed the concern with the DON regarding Resident #9 and #16's medication administration observations.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0760 (Tag F0760)

Could have caused harm · This affected 1 resident

Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident was free from a significant medication error. This was evident for 1 (Resident #236)...

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Based on observation, interview, and record review, it was determined that the facility failed to ensure a resident was free from a significant medication error. This was evident for 1 (Resident #236) of 5 resident medication administrations observed during the survey. The findings include: On 01/30/25 at 08:02 AM, the surveyor observed Registered Nurse Supervisor (RN) #22 administer 4 medications to Resident #236. On 01/30/25 at 08:15 AM, the surveyor observed RN #22 document the medications, which revealed 5 medications being signed off as administered, which included Bicalutamide 50MG, which was not observed to be prepared or administered to Resident #236. On 01/30/25 at 08:26 AM, review of Resident #236 Medication Administration Record (MAR) revealed 5 medications signed off, including Bicalutamide Tablet 50 MG (A drug used with another drug to treat prostate cancer that has spread to other parts of the body). On 01/31/25 at 12:52 PM, the surveyor obtained a MAR audit for Resident #236, which revealed the exact time that the medication was signed off, which indicated 01/30/25 at 08:16 AM. On 01/31/25 at 12:53 PM, the surveyor reviewed the concern with the DON regarding Resident #236's medication administration observation and MAR audit review. On 01/31/25 at 12:57 PM, the DON completed a pill count of the Bicalutamide medication with the Unit Manager/Staff #5 and the surveyor present. There were 26 pills counted to be in the bottle. On 01/31/25 at 12:58 PM, the surveyor observed a date of 1/27/25 on the pill bottle (which indicated the first date of which a pill was taken out the bottle). On 01/31/25 at 12:58 PM, an interview with the DON who was present during the observation revealed that the date written in would be the date a staff member opened the bottle. On 01/31/25 at 12:59 PM, review of the medication bottle label of Bicalutamide revealed a quantity of 30 pills, which indicated the amount of pills that were in the bottle prior to being opened. On 01/31/25 at 12:59 PM, further review of the medication bottle of Bicalutamide revealed administration instructions that read, take or use this medicine exactly as directed do not skip doses or discontinue unless directed by your doctor. On 01/31/25 at 01:07 PM, an interview with the DON revealed that if medication had been given each day since the bottle was opened on 1/27/25, then there would be a total of 25 pills left in the bottle at the time of the pill count. She was in agreement with the significant medication error finding.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0909 (Tag F0909)

Could have caused harm · This affected 1 resident

Based on observation, record review and staff interview, it was determined the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible ...

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Based on observation, record review and staff interview, it was determined the facility failed to conduct regular inspection of all bed frames, mattresses, and bed rails to identify areas of possible entrapment. This was evident for 2 (Resident #31 and #13) of 2 residents reviewed for accidents hazards. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. 1) On 01/29/25 at 08:14 AM, during the initial phase of the survey, the surveyor observed Resident #31 in bed with two 1/4 bed rails up on either side of the top end of the bed. 2) On 01/29/25 at 10:05 AM, during the initial phase of the survey, the surveyor observed Resident #13's bed in his/her room which revealed two 1/4 bed rails up on either side of the top end of the bed. On 01/30/25 at 11:17 AM, an interview with the Director of Maintenance (Staff #13) revealed that he would be unable to provide documentation of routine bedrail entrapment assessments completed for Resident #13 and #31. He indicated that maintenance completed routine checks of resident rooms, which did not include risk of entrapment assessments for those residents with transfer bars/bed rails.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected 1 resident

Based on record review and interview, it was determined that the facility failed to ensure there was a system in place to ensure Geriatric Nursing Assistants (GNAs) completed 12 hours of in-service tr...

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Based on record review and interview, it was determined that the facility failed to ensure there was a system in place to ensure Geriatric Nursing Assistants (GNAs) completed 12 hours of in-service training annually. This was evident for 3 (GNA #7, GNA #19, GNA #21) of 5 GNAs reviewed during the survey. The findings include: 1) On 01/30/25 at 3:19 PM, review of GNA #7's employee file revealed that Staff #7 received 3 hours of in-service training in 2024. 2) On 01/30/25 at 3:21 PM, review of GNA #19's employee file revealed that Staff #19 received 5 hours of in-service training in 2024. 3) On 01/30/25 at 3:24 PM, review of GNA #21's employee file revealed that Staff #21 received 0 hours of in-service training in 2024. On 01/31/25 at 10:10 AM, an interview with the Director of Nursing (DON) revealed that the facility was not in compliance with the 12 hour GNA annual in-service training for Staff #7, Staff #19, and Staff #21.
CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected multiple residents

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to ensure residents were treated with dignity and...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined that the facility failed to ensure residents were treated with dignity and respect. This was evident during observation of 19 rooms on 1 unit (Decker Unit) during the survey. The findings include: On 01/29/25 at 08:16 AM, the initial observation of the facility revealed rooms 406, 413, 416, 418, 419, 420, 421, 422, 424, 425, 426, 427, 428, 429, 430, 431, 432, 434, 435, which had over-the-door organizers on the outside of the doors. The organizers contained various resident care items, including briefs. On 01/31/25 at 08:15 AM, an interview with Resident #28, who resided in room [ROOM NUMBER], revealed that he/she did not know why the organizers were on the outside of the resident room door and was unhappy about it due to a privacy concern. On 01/31/25 at 2:05 PM, at the time of exit, the surveyor reviewed the concern regarding the failure to ensure residents are treated with dignity and respect.
CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Based on observations and interviews, it was determined that the facility staff failed to ensure canned goods and dry food were labeled with expiration dates and failed to label opened food with a use...

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Based on observations and interviews, it was determined that the facility staff failed to ensure canned goods and dry food were labeled with expiration dates and failed to label opened food with a used by date. This deficient practice was evident during the kitchen observation and has the ability to impact all residents who receive food from the kitchen. The findings include: On 01/29/25 at 10:33 AM, during an initial tour of the facility's kitchen with the Director of Dietary Services (DDS) #24 and Dietary Chef #25, the surveyor observed a rack of canned goods without an expiration date. When asked about the process for determining when to discard outdated canned goods the DDS #24 stated they were unsure and deferred the question to the Kitchen Chef #25. The Kitchen Chef #25 explained that can goods are ordered frequently, but the kitchen does not have a process in place to track expiration or best by date for canned goods. Next to the canned good rack, the surveyor along with the DDS #24, and Dietary Chef #25 observed an open cardboard box of Kellogg's Club Crackers containing individual packets. No expiration date was found on either the box or the individual cracker packets. When the surveyor inquired about the date the box was opened and expiration date, the DDS #24 and Dietary Chef #25 were unable to determine when it was opened or when it expired. At 10:40 AM, during a tour of the dairy refrigerator, the surveyor observed an open carton of heavy whipping cream without a label indicating the date it was opened or its discard date. When the surveyor mentioned the finding to the Dietary Chef #25, he immediately discarded the carton and acknowledged that it should have been labeled with both an open and discard date. When asked if labeling dairy products with these dates were the expectation of dietary staff, he confirmed that it was. On 01/30/25 at 01:54 PM, during a follow up tour of the facility's kitchen with the DDS #24, the surveyor observed that all canned goods were labeled with expiration dates, and the observed open box of Kellogg's Club Crackers had been discarded.
Feb 2020 4 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on medical record review and interview, it was determined the facility staff failed to thoroughly clarify a medication order with the physician for Resident (#228). This was evident for 1 of 29 ...

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Based on medical record review and interview, it was determined the facility staff failed to thoroughly clarify a medication order with the physician for Resident (#228). This was evident for 1 of 29 residents selected for review during the annual survey process. The findings include: Medical record review on 2/28/20 at 11:00 AM revealed on 9/27/19 the physician ordered: Hydralazine 50 milligrams by mouth 3 times a day as needed for blood pressure of systolic (top number) of above 160 or diastolic (bottom number) greater than 100. Hydralazine is used with or without other medications to treat high blood pressure. On 10/28/19 the physician ordered: Hydralazine 25 milligrams by mouth 3 times a day (not as needed but routine), hold for systolic blood pressure less than 110; however, the facility staff failed to clarify the Hydralazine order with the physician to determine if both medication orders were still valid. Interview with the medical director on 2/28/20 at 2:00 PM revealed the facility staff would not administer both ordered Hydrazine medications (as needed and routine). The medical director stated the facility nursing staff should have clarified the Hydralazine order and if needed discontinue the as needed order. Interview with the Director of Nursing on 2/28/20 at 2:00 PM confirmed the facility staff failed to thoroughly clarify a medication order with the physician for Resident #228.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Based on record review, observation and staff interview, it was determined the facility staff failed to ensure the resident's environment was free from potential accidents (#12 and #14). This was evid...

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Based on record review, observation and staff interview, it was determined the facility staff failed to ensure the resident's environment was free from potential accidents (#12 and #14). This was evident for 2 of 2 residents selected for review of accidents and 2 of 29 residents selected for review during the annual survey process. The findings include: The Minimum Data Set (MDS) is part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems. MDS assessments contain standardized questions about several elements of functional and cognitive status and mobility, Behavioral symptoms - a number of items about behavioral symptoms common in dementia, Psychosocial functioning - resident participation in activities and resident preferences, Symptoms and geriatric syndromes - for example pain, continence, falls, nutritional status, activities of daily living and many others and Diagnoses and medications - selected diagnoses and recent use of selected medications (e.g. antipsychotics, sedative-hypnotics) to name a few. 1. The facility staff failed to transfer Resident #12 with 2 staff members. Medical record review on 2/27/20 at 10:00 AM for Resident #12 revealed on 12/5/19 the facility staff assessed the resident and documented on the MDS: Section G- Activities of Daily Living, subs-section B: Transfer, how the resident moved between surfaces- to and from bed to chair, wheelchair. The facility staff documented the resident was an extensive assist and 2 persons assist for transfer. Further record review revealed the following Nurses' Note: 12/25/2019 9:35 PM: Note Text: patient fell while the aide was transferring resident from recliner chair to the wheelchair due to left leg weakness. Interview with the Director of Nursing on 2/28/20 at 2:00 PM confirmed the facility staff failed to provide an environment for Resident #12 free from accidents by transferring the resident with 1 staff member while being assessed to be a 2-person transfer. 2. The facility staff failed to maintain an environment free from potential accidents for Resident #14. Surveyor observation of Resident #14 on 2/26/20 at 11:00 AM and 2/27/20 at 9:00 AM revealed a bottle of Prevagen on the over bed table in the resident's room. Prevagen is a dietary supplement that has been clinically shown to help with mild memory loss associated with aging. Prevagen is formulated with apoaequorin, which is safe and uniquely supports brain function. When questioned, the resident stated the medication was for memory, but was not sure how well it worked. Review of the physician's ordered also failed to reveal an order for the medication. After surveyor inquiry, a physician's order was obtained for the Prevagen and the medication was removed to the medication cart for staff administration of the Prevagen. Interview with the Director of Nursing on 2/28/20 at 2:00 PM confirmed the facility staff failed to maintain an environment for Resident #14 free from potential accidents.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#24) with dietary interventions as ordered by the physician. This was eviden...

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Based on medical record review, observation and interview, it was determined the facility staff failed to provide Resident (#24) with dietary interventions as ordered by the physician. This was evident for 1 of 1 resident selected for review of nutrition care area and 1 of 29 residents selected for review during the annual survey process. The findings include: Medical record review for Resident #24 on 2/26/20 at 10:00 AM revealed on 11/3/19 the physician in collaboration with the Speech Language Pathologist ordered: Please place one type of food for meals to increase self-feeding. Place light color foods in dark bowls and dark color foods in light bowls for visual contrast as the resident reported difficulty with eating + difficulty finding food on the plate. It was also ordered for Resident #24 to be provided a divided plate for easier access to food. A divided plate has raised walls for scooping food onto silverware for those who have limited mobility and need assistance when eating. Surveyor observation of Resident #24 on 2/26/20 at 9:00 AM, 2/27/20 at 8:19 AM and 2/27/20 at 12:30 revealed the resident eating. It was noted the facility staff failed to provide Resident #24 with a divided plate as ordered and failed to provide Resident #24 with a dark background for light foods and vice versa to increase visual contrast. It was noted Resident #24 with the same blue flat plate that all the other residents were eating off. Interview with the Director of Nursing on 2/28/20 at 2:00 PM confirmed the facility staff failed to provide Resident #24 with dietary interventions as ordered by the physician.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Medical Records (Tag F0842)

Could have caused harm · This affected 1 resident

Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record for Resident (#12) in the most accurate and complete form. This was evident for...

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Based on medical record review and interview, it was determined the facility staff failed to maintain the medical record for Resident (#12) in the most accurate and complete form. This was evident for 1 of 29 residents selected for review during the annual survey. The findings include: A medical record is simply a record of a resident's health and medical history. Consistent, current and complete documentation in the medical record is an essential component of quality resident care. Medical record review on 2/27/20 at 12:00 PM for Resident #12 revealed on 4/10/19 the physician ordered: Do not weigh, as the resident was admitted to hospice services. Hospice care is a special kind of care that focuses on the quality of life for people and their caregivers who are experiencing an advanced, life-limiting illness. Hospice care provides compassionate care for people in the last phases of incurable disease so that they may live as fully and comfortably as possible. On 12/5/19, Resident #12 was discharged from hospice services. Record review revealed the facility staff documented weights for Resident #12 on: 12/12/19, 12/16/19, 12/26/19, 12/31/19, 1/8/20, 1/14/20, 1/21/20, 1/27/20, 2/4/20, 2/10/20, 2/17/20 and 2/25/20; however, failed to obtain a physician's order to obtain the weights. Interview with the Director of Nursing on 2/28/20 at 2:00 PM confirmed the facility staff failed to maintain the medical record for Resident #12 in the most complete and accurate manner by failing to obtain a physicians' order to obtain weights.
Aug 2018 3 deficiencies
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Based on medical record review, observation and interview, it was determined the facility staff failed to administer a medication in a timed manner as ordered to a Resident (#20). This was evident for...

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Based on medical record review, observation and interview, it was determined the facility staff failed to administer a medication in a timed manner as ordered to a Resident (#20). This was evident for 1 of 17 residents selected for review during the survey process. The findings include: Medical record review for Resident #20 revealed on 11/24/17 the physician ordered: Levothyroxine 100 micrograms every morning for hypothyroidism. Levothyroxine is commonly used in the treatment of patients with hypothyroidism. Levothyroxine is often administered in the morning, on an empty stomach, to increase its absorption. Observation of medication pass on 8/14/18 revealed facility staff nurse #1 failed to administer the Levothyroxine until 10:10 AM (while Resident #20 was actively eating breakfast). Interview with the Director of Nursing on 8/15/18 at 1:13 PM revealed Levothyroxine is to be administered to Resident #20 at 9:00 AM (per resident's request and individualization of care). Interview with the Director of Nursing on 8/16/18 confirmed the facility staff failed to administer a medication to Resident #20 in accordance with the recommendations of the medication.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0761 (Tag F0761)

Could have caused harm · This affected 1 resident

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility staff failed to ensure medication cart was locked and content...

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, it was determined the facility staff failed to ensure medication cart was locked and contents were not assessable to staff, residents or visitors. This was evident for 1 of 2 medication carts observed on the unit during the survey process. The findings include: Surveyor observation of a medication cart on 8/13/18 at 8:10 AM was noted to be stationed in the hall near room [ROOM NUMBER]. At that time, it was also noted the medication cart was not locked and resident #4 was sitting in a wheelchair beside the medication cart. (The resident made no attempt to open any draw or touch any equipment on the cart). It was further noted, at 8:13 AM Geriatric Nursing Assistant (GNA) #1 approached the medication cart, opened the top draw of the cart and removed a hearing aid for Resident #4. After placing the hearing aid in place for Resident #20, GNA #1 took Resident #4 to breakfast and the medication cart remained unlocked. At 8:16 AM, GNA #2 walked past the medication cart and locked the cart. The Director of Nursing and Nursing Home Administrator was made aware of the surveyor's observation on 8/13/18 at 12:00 PM. (No other unlocked medication carts were noted during the rest of the survey process). Interview with the Director of Nursing on 8/16/18 confirmed the facility staff failed to ensure all medication carts were locked and the contents were not accessible to staff, residents and visitors.
CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Laboratory Services (Tag F0770)

Could have caused harm · This affected 1 resident

Based on medical record review and staff interview, it was determined that the facility staff failed to obtain laboratory tests as ordered by the physician for a resident (#33). This was evident for 1...

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Based on medical record review and staff interview, it was determined that the facility staff failed to obtain laboratory tests as ordered by the physician for a resident (#33). This was evident for 1 of 17 residents selected for review during the survey process. The findings include: Medical record review for Resident #33 revealed the physician ordered Coumadin to be administered daily for A Fib. Atrial fibrillation (also called A Fib) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications. Coumadin is an anticoagulant (blood thinner) and reduces the formation of blood clots. The physician determines the amount of Coumadin to be administered based on the results of the INR. The International Normalized Ratio (INR) measures the clotting tendency of blood. Further medical record review revealed on 7/24/18 the physician ordered an PT/INR to be done in one week on 7/31/18. Further medical record review revealed the PT/INR was not drawn 7/31/18 but was drawn the following week on 8/7/18. Interview with the Director of Nursing on 8/16/18 at 8:35 AM confirmed the facility staff failed to obtain PT/INR laboratory blood test as ordered by the physician on 7/31/18 for Resident #33.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated K - Pattern L - Widespread
Actual Harm
G - Isolated H - Pattern I - Widespread
Potential for Harm
D - Isolated E - Pattern F - Widespread
No Harm (Minor)
A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

  • "Can I speak with families of current residents?"
  • "What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths
  • • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
  • • No fines on record. Clean compliance history, better than most Maryland facilities.
Concerns
  • • 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.

About This Facility

What is Pickersgill Retirement Community's CMS Rating?

CMS assigns PICKERSGILL RETIREMENT COMMUNITY an overall rating of 3 out of 5 stars, which is considered average nationally. Within Maryland, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.

How is Pickersgill Retirement Community Staffed?

CMS rates PICKERSGILL RETIREMENT COMMUNITY's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 54%, compared to the Maryland average of 46%.

What Have Inspectors Found at Pickersgill Retirement Community?

State health inspectors documented 19 deficiencies at PICKERSGILL RETIREMENT COMMUNITY during 2018 to 2025. These included: 19 with potential for harm.

Who Owns and Operates Pickersgill Retirement Community?

PICKERSGILL RETIREMENT COMMUNITY is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 43 certified beds and approximately 33 residents (about 77% occupancy), it is a smaller facility located in TOWSON, Maryland.

How Does Pickersgill Retirement Community Compare to Other Maryland Nursing Homes?

Compared to the 100 nursing homes in Maryland, PICKERSGILL RETIREMENT COMMUNITY's overall rating (3 stars) is below the state average of 3.0, staff turnover (54%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.

What Should Families Ask When Visiting Pickersgill Retirement Community?

Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"

Is Pickersgill Retirement Community Safe?

Based on CMS inspection data, PICKERSGILL RETIREMENT COMMUNITY has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Maryland. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Pickersgill Retirement Community Stick Around?

PICKERSGILL RETIREMENT COMMUNITY has a staff turnover rate of 54%, which is 7 percentage points above the Maryland average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.

Was Pickersgill Retirement Community Ever Fined?

PICKERSGILL RETIREMENT COMMUNITY has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Pickersgill Retirement Community on Any Federal Watch List?

PICKERSGILL RETIREMENT COMMUNITY is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

PICKERSGILL RETIREMENT COMMUNITY

615 CHESTNUT AVENUE, TOWSON, MD 21204 | (410) 825-7423

C+
Trust Grade (65/100)
3.0
CMS Rating
19
Deficiencies

Strengths

  • 4-star staffing

Concerns

  • Review findings

Ask about: Rn Coverage

nursinghomedata.org | Data: CMS November 2025