Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alice Byrd Tawes Nursing Home during CMS and state inspections, most recent first.
The facility failed to transmit MDS assessments to CMS as required, affecting four residents. The MDS, crucial for care planning, was not transmitted for several residents, with assessments still in progress. The MDS director acknowledged the delay, and the facility was informed of the deficiency.
The facility failed to provide timely baseline care plan (BLCP) summaries to several residents and/or their representatives within 48 hours of admission, as required. This deficiency was identified during a survey, revealing a lack of documentation confirming that residents received their BLCPs, which include initial goals and a list of medications. The DON acknowledged the absence of necessary documentation, indicating a systemic issue in the facility's process for ensuring timely communication of care plans.
The facility failed to post required nurse staffing information on all floors during a recertification survey. Surveyors found that dry erase boards on the second and third floors lacked essential details such as the facility name, total number of staff, and actual hours worked. Interviews with the DON and a receptionist confirmed the absence of posted staffing information, with staffing binders found out of reach behind the nursing counter.
A recertification survey revealed deficiencies in food storage practices at a facility. Unlabeled and undated bags of brownies and cookies were found in the dessert freezer, and a blue rag was also discovered stored there. The Food Service Supervisor and Dietary Aide were unaware of the duration the food items had been stored and the reason for the rag's presence. The facility's policy requires all stored foods to be labeled and dated, which was not followed in this instance.
A facility failed to maintain and retrieve advance directives for a resident in their medical record. Although a living will and power of attorney were documented, the actual documents were missing from both the hard chart and electronic health record. A physician's note indicated prior counseling on advance directives, but the absence was confirmed by a social worker, who acknowledged the oversight.
A facility failed to document when the IDT determined a resident met the criteria for a Significant Change in Status Assessment (SCSA). The policy requires documentation of significant changes impacting multiple health areas, but no evidence was found in the resident's medical record. Interviews with staff confirmed the absence of documentation, indicating non-compliance with the facility's policy.
A facility failed to develop a comprehensive, person-centered care plan for a resident, as observed during a recertification survey. The resident, who preferred individual activities, was repeatedly found in bed without activity materials. The care plan intervention was incomplete, lacking specific details about the resident's preferred activities. The Activities Coordinator acknowledged the issue, confirming the resident's preferences and the incomplete care plan.
A facility failed to conduct a care plan meeting for a resident at the time of admission, as required. The resident reported not attending a care plan meeting since admission, and a review of medical records confirmed the absence of such a meeting around the time of the admission MDS assessment. The MDS Coordinator acknowledged the oversight, and no evidence of a meeting was provided to the survey team.
A facility failed to implement and monitor fall interventions for a resident with a history of falls. Despite a care plan requiring a low bed with a mat, the intervention was delayed and not consistently in place, leading to additional falls. Staff were unaware of the resident's fall precautions, and documentation inaccurately reflected the presence of the fall mat. The DON confirmed the absence of the mat, and the Administrator acknowledged the issue.
A facility failed to implement a nutrition intervention for a resident, resulting in further weight loss. The resident required assistance with eating, but observations showed they struggled to open food containers and had not consumed their meal without help. Staff interviews revealed inconsistencies in providing feeding assistance, and documentation was incomplete. The DON acknowledged the care plan did not reflect the current feeding assistance needs.
A facility failed to label oxygen tubing and humidifier bottles for a resident receiving respiratory care, as observed during a survey. The resident's oxygen equipment was not labeled with the date and time of placement, contrary to physician's orders. Interviews with staff revealed inconsistencies in understanding the protocol for changing and labeling the equipment, with one LPN unsure of the frequency of changes and another stating it should occur weekly. The TAR indicated a bi-weekly change requirement, highlighting a failure to adhere to orders.
A facility failed to ensure monthly Medication Regimen Reviews were completed by a pharmacist and did not respond to pharmacy recommendations in a timely manner. A resident's medication adjustment was not formally documented or addressed, and a recommendation to increase Symbicort was delayed by 82 days. The facility lacked a system to track pharmacy recommendations, contributing to the deficiency.
The facility failed to ensure all employees' immunizations and screenings were up to date, affecting infection prevention and control. A GNA lacked a TB screening, and an LPN lacked a Tdap immunization. The LNHA admitted the facility's policy did not require Tdap for all employees, only for the pediatric unit, and missing documentation was unavailable.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility staff failed to ensure that assessments were sent to the Centers for Medicare and Medicaid Services as required, which was evident for four out of seven residents reviewed for late reporting. The Minimum Data Set (MDS), a federally mandated assessment tool, was not transmitted for several residents, impacting the accuracy of care planning. During a review of clinical records, it was found that the discharge MDS for Residents #11, #51, #56, and #69 were still in progress and not transmitted. The MDS director acknowledged that most of these assessments were late, and the facility administrative staff were informed of this deficiency at the exit conference.
Failure to Provide Timely Baseline Care Plans
Penalty
Summary
The facility failed to provide a baseline care plan (BLCP) summary to residents and/or their representatives within 48 hours of admission, as required. This deficiency was identified during a recertification survey for six out of twelve residents reviewed. The BLCP is essential for ensuring continuity of care and includes initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services. It also includes a list of the resident's current medications. The absence of documentation confirming that residents or their representatives received a written copy of the BLCP within the stipulated time frame was a common issue across multiple cases. In several instances, the Director of Nursing (DON) acknowledged the lack of documentation verifying that residents or their representatives were presented with their BLCPs. For example, Resident #36's BLCP was completed after the required 48-hour window, and there were no signatures to confirm receipt by the resident or representative. Similarly, Resident #57's BLCP lacked documentation of receipt, and the field for the resident's signature was blank. These oversights indicate a systemic issue in the facility's process for ensuring timely communication of care plans to residents and their representatives.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post required nurse staffing information during a recertification survey. Upon entering the building, surveyors observed that no staffing information was posted on the first floor. During a tour of the second floor nursing unit, a dry erase board was found lacking the facility name, the total number of staff, and actual hours worked for 7 out of 11 nursing staff. Similarly, on the third floor, the dry erase board did not display the facility name, total number of staff, or actual hours worked for 10 out of 13 nursing staff. No other postings of staffing information were observed on these units. Interviews with the Director of Nursing (DON) and Front Desk Receptionist confirmed the absence of posted staffing information. The DON mentioned that a staffing binder was supposed to be available on the second floor nursing station counter, but it was found out of reach behind the nursing counter in the office area. The DON acknowledged that no paper copies were posted, only the boards and binders were used. The facility Administrator was informed of the concern, and the issue was reiterated during the exit conference.
Deficiency in Food Storage Practices
Penalty
Summary
During a recertification survey, a deficiency was identified in the facility's food storage practices. The surveyor, along with the Food Service Supervisor (FSS), conducted an inspection of the kitchen's refrigerator and freezers. In the dessert freezer, they found a large bag of brownies and a large bag of cookies stored in clear Ziplock bags without any labels or dates. When questioned, the FSS was unsure of how long these items had been stored. Dietary Aide, responsible for desserts, stated that the items were from the previous day and proceeded to label and date them only after being prompted by the surveyor. Additionally, a blue rag in a clear Ziplock bag was discovered on the middle shelf of the dessert freezer. The FSS and Dietary Aide were both unaware of why the rag was stored there. The facility's policy, as provided by the Food Service Director, mandates that all foods stored in the refrigerator or freezer must be covered, labeled, and dated with a use-by date. The presence of unlabeled food items and a non-food item in the freezer indicates a failure to adhere to this policy, potentially compromising food safety and increasing the risk of cross-contamination.
Failure to Maintain Advance Directives in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that advance directives for a resident were maintained and readily retrievable in their medical record. During the recertification survey, it was observed that the medical record for a resident included documentation of a living will and power of attorney, but the actual documents were not present in either the hard chart or electronic health record. The Maryland Medical Orders for Life Sustaining Treatment form indicated the resident had a healthcare agent, yet no advance directives were found in the medical record. A physician's note from earlier in the year documented that advanced directives counseling had occurred, but the absence of the actual documents was confirmed during an interview with a social worker. The social worker acknowledged the oversight and confirmed that the resident's advance directives were not in the medical record. This issue was highlighted during the exit conference with the surveyor.
Failure to Document Significant Change in Status Assessment
Penalty
Summary
The facility failed to document in the medical record when the Interdisciplinary Team (IDT) determined that a resident met the criteria for a Significant Change in Status Assessment (SCSA). This deficiency was identified during a recertification survey for one resident out of 33 reviewed. The facility's policy requires that a significant change in a resident's condition, which impacts more than one area of health status and requires interdisciplinary review, be documented in the medical record. However, for Resident #24, there was no evidence in the medical record indicating when the IDT determined the resident met the criteria for a significant change. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed that there was no documentation available to show that the resident met the criteria for a significant change on the specified date. The MDS Coordinator was unable to find any documentation related to the significant change assessment for the resident, and the Director of Nursing confirmed the absence of such documentation. This lack of documentation indicates a failure to adhere to the facility's policy on recording changes in a resident's condition.
Incomplete Care Plan for Resident Activities
Penalty
Summary
The facility failed to ensure a resident's care plan was comprehensively developed and person-centered, as observed during a recertification survey. The deficiency was identified for a resident who was reviewed for activities. On multiple occasions, the resident was observed in bed without any activity materials within reach, despite their preference for specific individual activities over group activities. The resident's care plan intervention, initiated in March, was incomplete and did not specify the independent activities the resident enjoyed. The Activities Coordinator confirmed the resident's preferences and acknowledged the incomplete care plan intervention, indicating an understanding of the concern.
Failure to Conduct Timely Care Plan Meeting
Penalty
Summary
The facility failed to hold care plan meetings for residents and/or their representatives at the time of their admission, as required. This deficiency was identified during a recertification survey, specifically for one resident out of 33 reviewed. The care plan is a critical tool used to address the unique needs of each resident, and it is essential for planning, assessing, and evaluating the effectiveness of the resident's care. In this case, the resident, identified as Resident #18, reported not having attended a care plan meeting since her admission to the facility. Upon review of Resident #18's medical records, it was found that the resident was admitted earlier in the year, and an admission MDS assessment was completed in February. However, there was no documentation of a care plan meeting held around the time of this assessment. The MDS Coordinator, responsible for scheduling these meetings, confirmed that a care plan meeting was not held in February and acknowledged that it was missed. Despite requests from the survey team, no evidence was provided to show that a care plan meeting had taken place for the resident around the time of the admission MDS assessment.
Failure to Implement and Monitor Fall Interventions
Penalty
Summary
The facility failed to ensure and monitor the implementation of fall interventions for a resident with an extensive fall history. The resident, who was at high risk for falls, had experienced multiple falls in October 2024. Despite a care plan intervention requiring a low bed with a mat to be in place after falls on 10/15/24 and 10/18/24, this intervention was not implemented until 10/24/24. Even after implementation, the resident sustained two additional falls on 10/31/24, and during a surveyor's observation on 11/19/24, no fall mat was found in the resident's room. The surveyor's investigation revealed that the nursing staff, including an RN and LPN, were unaware of the current fall precautions for the resident. The RN assigned to the resident's care was unfamiliar with the resident and had to confirm their assignment. The DON confirmed the absence of the fall mat, which should have been present in the room. Additionally, documentation inaccurately indicated that the fall mat had been in place, despite its absence. The facility's Administrator acknowledged the surveyor's concerns during the exit conference.
Failure to Implement Nutrition Intervention for Resident
Penalty
Summary
The facility failed to implement a nutrition intervention for a resident, leading to further weight loss. Upon admission, the resident weighed 114.2 lbs and later weighed 103.9 lbs, indicating weight loss. The resident was documented as needing partial/moderate assistance for eating, and a nutrition note indicated that the resident ate 100% when fed by staff. However, observations revealed that the resident was unable to feed themselves and required assistance, which was not consistently provided. The resident was observed struggling to open food containers and had not consumed any food items on their tray without assistance. Staff interviews revealed inconsistencies in the process of ensuring residents received feeding assistance. A registered nurse acknowledged the need for assistance but noted that staff often had to figure out feeding arrangements among themselves. Documentation of the resident's meal consumption and assistance level was not completed as expected. The Director of Nursing acknowledged that the care plan did not reflect the most current feeding assistance requirements and stated that it should be updated at the time of any change.
Failure to Label Oxygen Equipment
Penalty
Summary
The facility failed to properly label oxygen tubing and humidifier bottles for a resident receiving respiratory care, as observed during a recertification survey. On two separate occasions, a surveyor noted that the oxygen tubing and humidifier bottle for a resident using a nasal cannula with 2 liters of oxygen were not labeled with the date and time they were placed. This deficiency was identified for one resident reviewed for respiratory care. Interviews with staff revealed inconsistencies in the understanding and execution of the facility's protocol for changing and labeling oxygen equipment. One LPN was unsure of the frequency of tubing changes, while another LPN stated that the tubing and humidifier should be changed every Sunday night by the night shift nurse, with the changes documented on the Medication Administration Record (MAR) or Treatment Administration Record (TAR). However, a review of the TAR showed an order to change the equipment every two weeks and as needed, with labeling required. The lack of labeling indicated a failure to follow the physician's orders and facility protocol.
Failure to Complete and Respond to Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Reviews (MRR) were completed by the pharmacist and did not respond to recommendations made by consulting pharmacists in a timely manner. This deficiency was identified during a recertification survey for a resident who was reviewed for unnecessary medications. The pharmacist documented a recommendation to decrease levothyroxine due to a low TSH level in the resident's medical record, but there was no formal recommendation sent to the facility for August 2024. The Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) were unaware of this recommendation, and the pharmacist confirmed that no entry was made for the resident in August 2024. Additionally, the facility did not address a pharmacy recommendation made in September 2024 to increase the dose of Symbicort for the resident. The recommendation was not acted upon within the facility's expected timeline of 7-14 days. The LNHA acknowledged that the recommendation was not addressed until surveyor intervention, 82 days after it was made. The physician eventually disagreed with the recommendation, providing a rationale and signing the document only after the surveyor's involvement. The lack of a system to ensure all pharmacy recommendations were received and addressed contributed to the deficiency. The LNHA admitted that there was no current system in place to track which pharmacy recommendations should be received monthly. This oversight led to a delay in addressing the pharmacist's recommendations, impacting the resident's medication management and potentially their health outcomes.
Deficiency in Employee Immunization and Screening Documentation
Penalty
Summary
The facility failed to ensure that all employees' required immunizations and screenings were up to date, as part of their infection prevention and control program. During a recertification survey, it was found that two out of five employees reviewed did not have the necessary documentation on file. Specifically, a Geriatric Nursing Assistant (GNA) did not have a documented TB screening, and a Licensed Practical Nurse (LPN) did not have a documented Tdap immunization. In an interview, the Licensed Nursing Home Administrator acknowledged that the facility's employee health procedures did not require Tdap immunizations for all employees, only for those in the pediatric unit, and admitted that any missing documentation was not available. The facility's policy requires two-step TB testing for all new team members and annual TB assessments, as well as a single dose of Adult Tdap for new team members and those in high-risk areas, which includes the nursing home.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 76 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crisfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hartley Nursing And Rehab | 16.8 mi | — | 32 | 0 |
| Manokin Nursing And Rehab | 16.9 mi | — | 44 | 2 |
| Shore Health & Rehab Center | 20.6 mi | — | 0 | 0 |
| Snow Hill Rehabilitation & Healthcare Center | 27.6 mi | — | 5 | 0 |
| Anchorage Rehabilitation And Wellness Center | 28.9 mi | — | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Alice Byrd Tawes Nursing Home.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.