South Mountain Rehab Center
141 South Main Street · Boonsboro, MD · 21713 · 3014325457
157 certified beds For profit - Limited Liability company
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
- No federal fines or payment denials in CMS’s 3-year window.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 2 of 5 Inspections: 2 of 5 Staffing: 2 of 5 Quality measures: 3 of 5
| Total nurse hours / resident-day | 3.37 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.61 | 0.55–0.75 |
| Weekend hours / resident-day | 3.04 | ≈ weekday level |
| Nursing turnover / year | 48% | median 45% |
| Fines (3-yr window) | none |
Inspection citations (48 in the current record)
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Immediate jeopardy · J April 22, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Past Non-Compliance · Quality of Life and Care
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Potential for harm · D December 20, 2024
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected January 31, 2025 · Resident Rights
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Potential for harm · E December 20, 2024
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected January 31, 2025 · Resident Rights
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Potential for harm · D December 20, 2024
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected January 31, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 20, 2024
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected January 31, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 20, 2024
Ensure each resident receives an accurate assessment.
Corrected January 31, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 20, 2024
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected January 31, 2025 · Resident Assessment and Care Planning
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Potential for harm · D December 20, 2024
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected January 31, 2025 · Resident Assessment and Care Planning
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Potential for harm · E December 20, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 31, 2025 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Provide activities to meet all resident's needs.
Corrected January 31, 2025 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Provide 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.
Corrected January 31, 2025 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 31, 2025 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Provide enough food/fluids to maintain a resident's health.
Corrected January 31, 2025 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Provide safe, appropriate pain management for a resident who requires such services.
Corrected January 31, 2025 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Provide care or services that was trauma informed and/or culturally competent.
Corrected January 31, 2025 · Quality of Life and Care
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Potential for harm · D December 20, 2024
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected January 31, 2025 · Nursing and Physician Services
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Potential for harm · E December 20, 2024
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected January 31, 2025 · Pharmacy Service
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Potential for harm · D December 20, 2024
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected January 31, 2025 · Pharmacy Service
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Potential for harm · D December 20, 2024
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected January 31, 2025 · Pharmacy Service
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Potential for harm · D December 20, 2024
Ensure medication error rates are not 5 percent or greater.
Corrected January 31, 2025 · Pharmacy Service
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Potential for harm · D December 20, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected January 31, 2025 · Pharmacy Service
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Potential for harm · D December 20, 2024
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected January 31, 2025 · Nutrition and Dietary
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Potential for harm · D December 20, 2024
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected January 31, 2025 · Administration
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Potential for harm · E December 20, 2024
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected January 31, 2025 · Administration
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Potential for harm · D December 20, 2024
Provide and implement an infection prevention and control program.
Corrected January 31, 2025 · Infection Control
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 215144 · certified since April 1, 1983. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.