Your report for Creekside Center for Rehabilitation and Nursing
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- MarylandLowest tier among peers219 rated homes · average 3.1★
- Washington CountyLowest tier among peers10 rated homes · average 2.0★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs MD avg
- StaffingCan add or remove a star2★−1.1 vs MD avg
- Quality measuresCan add or remove a star2★−1.8 vs MD avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Special Focus Facility candidateThis facility is on the CMS candidate list for the Special Focus Facility program, meaning it is among the poorest-performing facilities in its state on recent inspections.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersMD avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover2★Above only 7% of peersMD avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 5% of peersMD avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.28hrsAbove only 6% of peersMD avg3.90Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.70hrsAbove 52% of peersMD avg0.83Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better74%Lowest tier among peersMD avg41%RN turnover70%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$101,178Above only 6% of peersMD avg$24,026Fines · denials1 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2018 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 23, 2025Cycle 1worst J · immediate jeopardy
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Nov 24, 2025
Oct 17, 2025Cycle 1worst G · actual harm
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 3, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Dec 3, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Feb 4, 2025
Feb 21, 2025Cycle 1worst E · no actual harm
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Mar 31, 2025
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 31, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Mar 31, 2025
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Mar 31, 2025
Aug 5, 2024Cycle 1worst J · immediate jeopardy$101,178
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Nov 22, 2024
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Nov 22, 2024
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected Oct 8, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareJ · isolatedCorrected Nov 22, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Oct 8, 2024
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Oct 7, 2024
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsD · isolatedCorrected Oct 8, 2024
- F572Give residents a notice of rights, rules, services and charges.Resident RightsD · isolatedCorrected Oct 8, 2024
- F578Honor 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.Resident RightsD · isolatedCorrected Nov 22, 2024
- F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 8, 2024
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Oct 8, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Nov 22, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Nov 22, 2024
- F637Assess the resident when there is a significant change in conditionResident Assessment and Care PlanningD · isolatedCorrected Oct 8, 2024
- F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
- F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician ServicesD · isolatedCorrected Oct 8, 2024
- F727Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.Nursing and Physician ServicesF · widespreadCorrected Oct 8, 2024
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesF · widespreadCorrected Nov 22, 2024
- F732Post nurse staffing information every day.Nursing and Physician ServicesD · isolatedCorrected Oct 8, 2024
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Oct 8, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Oct 8, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Oct 8, 2024
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationF · widespreadCorrected Nov 22, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Oct 8, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationF · widespreadCorrected Nov 22, 2024
- F868Have the Quality Assessment and Assurance group have the required members and meet at least quarterlyAdministrationD · isolatedCorrected Oct 8, 2024
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Oct 8, 2024
- F941Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.AdministrationF · widespreadCorrected Nov 22, 2024
- F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Freedom from Abuse, Neglect, and ExploitationF · widespreadCorrected Oct 8, 2024
- F945Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.Infection ControlF · widespreadCorrected Oct 8, 2024
- F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesF · widespreadCorrected Nov 22, 2024
- F949Provide behavior health training consistent with the requirements and as determined by a facility assessment.AdministrationF · widespreadCorrected Nov 22, 2024
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
- F697Provide safe, appropriate pain management for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
- F838Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.AdministrationF · widespreadCorrected Nov 22, 2024
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Oct 8, 2024
- F604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.Freedom from Abuse, Neglect, and ExploitationJ · isolatedCorrected Nov 22, 2024
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Oct 8, 2024
- F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Nov 22, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Oct 8, 2024
- F660Plan the resident's discharge to meet the resident's goals and needs.Resident Assessment and Care PlanningF · widespreadCorrected Nov 22, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Nov 22, 2024
- F711Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.Nursing and Physician ServicesE · patternCorrected Oct 8, 2024
- F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesD · isolatedCorrected Nov 22, 2024
- F744Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.Quality of Life and CareD · isolatedCorrected Oct 8, 2024
Jul 25, 2019Cycle 2worst J · immediate jeopardy
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Sep 25, 2019
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceD · isolatedCorrected Sep 25, 2019
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Sep 25, 2019
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Nov 19, 2019
- F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryE · patternCorrected Sep 25, 2019
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationD · isolatedCorrected Sep 25, 2019
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Nov 19, 2019
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsD · isolatedCorrected Sep 25, 2019
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationE · patternCorrected Sep 25, 2019
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Nov 19, 2019
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Sep 25, 2019
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Sep 25, 2019
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsB · patternCorrected Sep 25, 2019
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 25, 2019
- F602Protect each resident from the wrongful use of the resident's belongings or money.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Sep 25, 2019
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Sep 25, 2019
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected Sep 25, 2019
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Sep 25, 2019
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Sep 25, 2019
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Sep 25, 2019
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Nov 19, 2019
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareE · patternCorrected Sep 25, 2019
- F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Sep 25, 2019
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Sep 25, 2019
- F692Provide enough food/fluids to maintain a resident's health.Quality of Life and CareD · isolatedCorrected Sep 25, 2019
- F725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.Nursing and Physician ServicesE · patternCorrected Nov 19, 2019
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Nov 19, 2019
Feb 5, 2018Cycle 3worst F · no actual harm
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Mar 28, 2018
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Mar 28, 2018
- F770Provide timely, quality laboratory services/tests to meet the needs of residents.AdministrationD · isolatedCorrected Mar 28, 2018
- F790Provide routine and 24-hour emergency dental care for each resident.Quality of Life and CareD · isolatedCorrected Mar 28, 2018
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Mar 28, 2018
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationF · widespreadCorrected Mar 28, 2018
- Ensure each residentâs drug regimen must be free from unnecessary drugs.Pharmacy ServiceE · patternCorrected Mar 28, 2018
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareE · patternCorrected Mar 28, 2018
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Mar 28, 2018
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Mar 28, 2018
- F559Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.Resident RightsC · widespreadCorrected Mar 28, 2018
- F578Honor 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.Resident RightsD · isolatedCorrected Mar 28, 2018
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected Mar 28, 2018
- F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsE · patternCorrected Mar 28, 2018
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningE · patternCorrected Mar 28, 2018
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Mar 28, 2018
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Mar 28, 2018
- F675Honor each resident's preferences, choices, values and beliefs.Quality of Life and CareD · isolatedCorrected Mar 28, 2018
- F710Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.Nursing and Physician ServicesD · isolatedCorrected Mar 28, 2018
- F712Ensure that the resident and his/her doctor meet face-to-face at all required visits.Nursing and Physician ServicesE · patternCorrected Mar 28, 2018
- F730Observe each nurse aide's job performance and give regular training.Nursing and Physician ServicesE · patternCorrected Mar 28, 2018
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Mar 28, 2018
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Mar 28, 2018
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Mar 28, 2018
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.28hrs
- Registered nursesRN hours only0.70hrs
- Licensed practical nursesLPN hours0.68hrs
- Nurse aidesCNA hours1.90hrs
- Weekend nursingAll staff on Saturdays and Sundays3.09hrs
- Maryland average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better74%Lowest tier among peersMD avg 41%
- RN turnoverRegistered nurses only70%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy80 certified beds · ~75 residents a day94%Above 79% of peersMD avg 83%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $101,178In fines
- 1Fine
- 0Payment denials
- $24,026MD avg in fines
Actions on record
- Aug 5, 2024Civil money penalty$101,178
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Mordechai Weisz7 facilities in the chain2.4★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Mordechai Weisz
- Lions Healthcare Management LLC
- Ahmed Elebiary
- Cynthia Truslow
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 215113 · 1183 LUTHER DRIVE, HAGERSTOWN, MD, 21740.
- Percentiles compare this facility with every rated nursing home in Maryland and Washington County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









