Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Healthcare At College Park, Llc during CMS and state inspections, most recent first.
The facility failed to maintain a clean ice machine, which had a black residue buildup due to inadequate cleaning. The ice machine was observed to have a buildup inside, and there was no ice scoop available. The facility's log showed the last cleaning on the inspection day, but no issues were noted. Staff interviews revealed a lack of awareness and responsibility for the ice machine's maintenance, with the Administrator acknowledging no policy existed and attributing the issue to a need for staff education.
The facility failed to maintain an effective Antibiotic Stewardship Program, as evidenced by incomplete documentation and inconsistent infection tracking. Despite policies requiring detailed antibiotic orders and specific information for suspected infections, there were instances of antibiotic starts without corresponding infections or documentation. The Infection Preventionist acknowledged the need for improved documentation, while the DON claimed monitoring was in place, yet inconsistencies persisted.
A facility failed to administer 5:00 pm medications to seven residents due to a CMA's inability to access the EHR, leading to reliance on a paper list. The medications were not given and were found in the pharmacy return receptacle. The DNS confirmed the issue and noted that the facility's policy requires timely administration and documentation of medications.
A facility failed to administer scheduled medications to several residents, as observed when a CMA did not pass 5:00 pm medications and failed to notify licensed staff. The medications, including Potassium Chloride, Venlafaxine, and others, were found in the cart drawer later. The DON confirmed the medications were not signed for, and the LPN unit manager and provider extender were not informed of the missed doses.
A resident with multiple medical conditions was sexually abused by another resident with a history of aggressive behavior. The incident was substantiated, and the offending resident was transferred for psychiatric evaluation. Despite the facility's policy, there was a failure to prevent repeated aggressive incidents, indicating a lapse in protective measures.
A facility failed to implement PASARR level II recommendations for a resident, including specialized mental health services and behavioral health monitoring. The DON acknowledged the lack of documentation and oversight in providing the necessary care, despite the resident's history of suicidal ideations and behavioral episodes. The Administrator noted that the social services coordinator is responsible for ensuring PASARR recommendations are followed.
A facility failed to develop a comprehensive care plan for a resident with end-stage renal disease who required dialysis three times a week. The MDS coordinator was unaware of their responsibility to create a care plan addressing the resident's specific needs, and the DON confirmed it was the coordinator's duty. This oversight resulted in a deficiency in the care planning process.
A resident with paraplegia and neuromuscular dysfunction of the bladder was not checked and changed for incontinence care for over four hours, despite facility policy requiring checks every two hours. The CNA responsible did not realize the lapse in time, and the DON was unaware of the oversight.
The facility failed to secure a central supply room containing medications and medical supplies. An LPN confirmed the room was open and not locked, despite the presence of over-the-counter medications. The DON revealed that the room should have been shut and locked, as per the facility's policy requiring all medications to be stored in locked compartments.
A resident with an external catheter was not properly protected from infection risk due to staff failing to use PPE as required by enhanced barrier precautions. Despite signage indicating the need for PPE, two CNAs entered the resident's room without it. Interviews revealed a lack of awareness and understanding of the PPE requirements, highlighting a communication lapse in the facility's infection control protocols.
Ice Machine Maintenance Deficiency
Penalty
Summary
The facility failed to ensure the cleanliness and proper functioning of the ice machine, which was found to have a black residue buildup due to inadequate cleaning. During a kitchen tour, it was observed that the ice machine had not been properly maintained, as evidenced by the black buildup inside where the ice is made. The facility's log indicated that the ice machine was last cleaned on the same day as the inspection, but no issues were noted in the log. Additionally, there was no ice scoop available near the machine. Interviews revealed a lack of awareness and responsibility among staff regarding the maintenance of the ice machine. The Administrator admitted there was no policy for the ice machine and attributed the buildup to a need for in-service education for the responsible staff. The Dietary Kitchen Manager was unaware of the machine's condition and stated that housekeeping and maintenance staff were responsible for its cleaning.
Deficient Antibiotic Stewardship Program
Penalty
Summary
The facility failed to properly maintain an Antibiotic Stewardship Program, which is designed to monitor the use of antibiotics in residents. The policy requires that prescribers provide complete antibiotic orders, including drug name, dose, frequency, duration, route of administration, and indications for use. Additionally, when a nurse communicates a suspected infection to a physician, they must have specific information available, such as signs and symptoms, hydration status, and current medication list. However, the facility's documentation and infection surveillance were found lacking. For instance, in several months, there were antibiotic starts without corresponding infections or documentation of signs and symptoms, indicating a failure to adhere to the stewardship program's guidelines. The Infection Preventionist (IP), who has been in the position since March 2024, acknowledged the need for improved documentation and communication with providers to ensure antibiotics are only ordered when criteria are met. The Director of Nursing stated that all antibiotic use is monitored and infections are trended, but the report indicates inconsistencies in documentation and infection tracking. For example, in July 2024, there were no infections reported, yet four antibiotic starts occurred. Similarly, in March 2024, there were nine infections listed without detailed information about signs and symptoms, highlighting a gap in the facility's infection control practices.
Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to administer 5:00 pm medications on 8/9/24 for seven residents, which was identified through observation, interview, and record review. The Certified Medication Aide (CMA) FF was responsible for administering medications on the first floor and used a paper list to pass medications due to an issue with her electronic health record (EHR) password. Despite having medication pouches prepared, the medications for the 5:00 pm pass were not administered, and the pouches were instead placed in a separate drawer in the medication cart. The Director of Nursing Services (DNS) confirmed that the medications for the seven residents were found in the pharmacy return receptacle and acknowledged that the CMA should have reported the issue to a nurse. The DNS was aware of the password issue and had contacted IT for a reset, but could not recall when it was completed. The facility's policy required medications to be administered within one hour of the prescribed time, and any deviations were to be documented. However, the 5:00 pm and 9:00 pm medications were not signed for on 8/6/24, indicating a failure to adhere to the policy.
Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to ensure that seven of nine sampled residents were free from significant medication errors, as medications were not administered according to physician orders. On the evening of August 6, 2024, a Certified Medication Aide (CMA) was observed passing medications for first-floor residents and it was noted that several residents did not receive their scheduled 5:00 pm medications. These medications included Potassium Chloride, Venlafaxine, Levetiracetam, Memantine, Metoprolol Tartrate, Niacin, Renvela, Xarelto, and Gabapentin. The CMA did not notify licensed staff about the missed medications, and the medications were found in the cart drawer later that evening. The Director of Nursing (DON) confirmed that the medications were not administered and were not signed for on the medication administration records. The Licensed Practical Nurse (LPN) unit manager and a provider extender were not informed of the missed medications, and no reports of adverse effects were received. The facility's policy requires staff to contact the prescriber or medical director if a medication is believed to be excessive, inappropriate, or associated with adverse effects, but this protocol was not followed in this instance.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident, identified as R5, from sexual abuse by another resident, R425. R5, a female with multiple medical conditions including multiple sclerosis and major depressive disorder, was reportedly groped by R425, a male resident with a history of cerebral infarction and major depressive disorder. The incident was substantiated on the same day it was reported, and R425 was transferred to a local hospital for psychiatric evaluation. Despite the facility's policy requiring the administrator to determine necessary actions upon receiving abuse allegations, the report indicates that R425 had a history of hitting and groping other residents, suggesting a potential lapse in preventive measures. R5 reported feeling safe after the incident was addressed, but she also mentioned that R425 had previously hit her, indicating a pattern of aggressive behavior that was not adequately managed. The Director of Nursing confirmed the substantiated abuse allegation and noted that the two residents had a history of conflict. The facility's administrator, who was not employed at the time of the incident, could not comment on the management of multiple allegations involving R425. This deficiency highlights a failure in the facility's responsibility to protect residents from abuse, as outlined in their policy.
Failure to Implement PASARR Level II Recommendations
Penalty
Summary
The facility failed to follow the PASARR level II program recommendations for a resident with a PASARR level II determination. The recommendations included specialized mental health services such as psychiatric care for assessment and medication monitoring, behavioral health monitoring, individual counseling, and crisis intervention. The facility's Director of Nursing (DON) acknowledged that while a behavioral health assessment was completed, the resident did not receive any psych therapies, and there was no documentation of behavioral health monitoring in the medical records. The DON admitted that the behavior monitoring was not documented on the Medication Administration Record (MAR) and was unsure how this oversight occurred. The resident had a history of suicidal ideations and behavioral episodes, particularly related to interactions with her boyfriend. Despite these issues, the facility did not provide the recommended specialized services or document the necessary monitoring. The DON noted that the recommendations were care planned but not fully implemented, and staff did not receive any special training beyond quarterly behavioral health training. The facility's Administrator, who was not present during the resident's stay, stated that the social services coordinator is responsible for reviewing and auditing PASARR recommendations to ensure they are in place.
Failure to Develop Comprehensive Care Plan for Dialysis-Dependent Resident
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R45, that was consistent with the resident's specific conditions, risks, needs, and current standards of practice. R45, who has end-stage renal disease and is dependent on renal dialysis, was scheduled to receive dialysis treatment three times a week. Despite this, the care plan did not reflect these specific needs. Interviews revealed that the MDS coordinator was unaware of their responsibility to develop a care plan related to the resident's specific conditions, and the Director of Nursing stated that it was the MDS coordinator's responsibility to develop the care plan. This lack of awareness and communication led to the deficiency in the care planning process.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide adequate care for a resident, identified as R14, who was dependent on staff for activities of daily living, specifically incontinence care. R14, who has a BIMS score of 15 indicating no cognitive impairment, suffers from conditions including neuromuscular dysfunction of the bladder and paraplegia, which prevent her from feeling anything below her waist and recognizing when she is wet or soiled. On the day of the observation, R14 reported that her brief was last changed at 12:00 pm before lunch. During an interview, a CNA admitted to not checking R14's brief until notified by the surveyor at 4:12 pm, despite offering hydration at 3:00 pm. The CNA acknowledged that R14 needed to be changed at 4:18 pm and was unaware that more than two hours had passed since the last check and change. The Director of Nursing confirmed that residents dependent on staff for incontinence care should be checked and changed every two hours, and was unaware that R14 had not been attended to since before lunch.
Failure to Secure Central Supply Room
Penalty
Summary
The facility failed to secure a central supply storage room containing medications and medical supplies. On August 7, 2024, at 3:03 pm, the central supply room on the first floor was observed to be open with no staff present. At 3:05 pm, an LPN confirmed the room was open and not locked, stating that they had never been instructed to keep it closed and locked, despite the presence of over-the-counter medications. The Director of Nursing later revealed that the room belonged to the central supply clerk and the scheduler, and confirmed that it should have been shut and locked. The facility's Medication Labeling and Storage policy, revised in February 2023, requires all medications and biologicals to be stored in locked compartments, accessible only to authorized personnel.
Failure to Use PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to protect a resident, identified as R37, from the risk of infection due to improper use of personal protective equipment (PPE) by staff. R37, who was admitted with multiple diagnoses including quadriplegia and diabetes, was on enhanced barrier precautions due to having an external catheter. Despite the requirement for staff to don PPE when providing care to R37, observations revealed that two certified nurse's aides (CNAs) entered the resident's room without wearing the necessary protective gear. The room had signage indicating the need for enhanced barrier precautions, yet the CNAs proceeded without adhering to the protocol. Interviews with the CNAs involved revealed a lack of awareness and understanding of the PPE requirements. One CNA admitted she was not informed about the need for PPE, while the other initially misunderstood the signage but later acknowledged the requirement. The Director of Nursing confirmed the expectation for staff to wear PPE in designated rooms to protect residents, indicating a lapse in communication and training regarding infection control protocols.
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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.
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Nursing homes near College Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bonterra Transitional Care & Rehabilitation | 2 mi | ★★★★★ | 5 | 0 |
| Fulton Center For Rehabilitation Llc | 2.4 mi | ★★★★★ | 0 | 0 |
| Crestview Health & Rehab Ctr | 2.4 mi | ★★★★★ | 9 | 3 |
| Reliable Health & Rehab At Lakewood | 3.3 mi | ★★★★★ | 12 | 0 |
| Riverdale Center For Nursing And Healing | 6.2 mi | ★★★★★ | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.