Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 Collingswood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff failed to timely report injuries of unknown origin for two residents to state authorities. In one case, a family member informed a GNA about a contusion on a resident’s upper arm, but the GNA did not assess the resident and forgot to notify a nurse or other staff, and the injury was not brought to administration’s attention until the family later emailed the ADON, resulting in a multi-day delay in reporting to OHCQ. In the other case, nursing staff identified and treated a bruise on a resident’s thigh and informed the Dementia Unit Manager, who did not notify the DON or Administrator until several days later, causing a late Facility Reported Incident submission to OHCQ.
The facility failed to thoroughly investigate both an abuse allegation and an injury of unknown source. An alert, newly admitted resident with complex medical needs reported in writing being beaten during bath time on the second day of admission, but there was no documented resident interview, no interviews with other residents on the unit, incomplete staff interviews across all shifts, and no written statement from the nurse manager who received the allegation. In a separate case, a severely cognitively impaired, ventilator‑dependent resident exhibited pain with right arm movement, and an initial x‑ray suggested a wrist fracture later not confirmed at the hospital; however, the facility’s investigation only included statements from staff present at the time of the observed pain and one assisting GNA, with no interviews of staff from prior shifts or any residents regarding the injury of unknown source.
A resident who was his/her own decision maker received a notice of non-coverage with a planned discharge date and initially agreed to go home, with Social Services documenting plans for home health and transportation by taxi. After the resident’s family member told the Social Services assistant they wanted to appeal the discharge and believed the resident needed more time, the assistant informed staff that the resident would be staying and told the resident about the family’s wishes, but did not document this change in the discharge plan or the appeal in the medical record, resulting in an incomplete and inaccurate record.
Unlabeled stored food items were found during kitchen tours, including produce, cheese, chicken, ground beef, tortillas, hoagies, broccoli, sausages, lamb patties, and butter. A Dietary Aide stated that items should have had received-by dates or used-by dates as applicable, and the FSD was later informed of the concerns.
The facility failed to address repeated resident grievances raised in Resident Council meetings and did not clearly inform residents or staff how to file concerns. Residents reported unanswered call lights, missing clothing, broken glasses, loud staff, housekeeping issues, and delayed maintenance, but there was no evidence these concerns were resolved or that residents were notified of outcomes. Surveyors also found no visible grievance postings, inconsistent staff knowledge of where forms were kept, and no written grievance process in the admission packet.
A facility failed to complete BLCPs within 48 hours of admission and failed to provide BLCP summaries, including current med lists, to the resident and/or RP for three residents. Record review showed no BLCPs for the residents, and the DSS stated she could not produce the requested documentation when asked by the surveyor.
Unsafe lift use and inadequate supervision of cognitively impaired residents: A resident with severe cognitive impairment became cyanotic and unresponsive during a Hoyer lift transfer when staff used an oversized sling and could not lower the lift right away, with family assisting and an untrained GNA operating the device. Two other residents from a locked dementia unit were observed without proper supervision, including one left unattended by the elevator while going to dialysis and another reaching into a nurses’ station drawer containing batteries and other items.
A facility failed to keep emergency clamps at the bedside for residents receiving dialysis who had orders for an AV fistula clamp to be in the room at all times. During room checks, a surveyor found no clamp in the room of one resident on dialysis, and staff could not locate one; the DON confirmed a clamp should be present. Additional checks found no clamp in the rooms of four other residents on dialysis with the same order.
Infection control practices were not followed when four laundry bins contained used linens and residents' clothing that were not bagged before transfer to the laundry room. In addition, two residents on EBP did not have precaution signage posted on their room doors, and the DON, IP, and Regional IP gave differing explanations for the missing signs.
Incomplete Annual GNA In-Service Training: The facility failed to ensure GNAs completed the required 12 hours of annual in-service training. Review of training files showed three GNAs had far less than the required hours across one or more years, and the Staff Developer/Educator confirmed they had not completed the required training. The HR Director stated the annual training was completed through Relias upon hire and then annually, but the records did not reflect completion for these staff members.
Delayed Response to Resident Call Bell: A resident with a tracheostomy and tube feeding had a call bell active for 113 minutes before staff responded. A nurse confirmed the prolonged activation, while a GNA later said the resident had likely pressed it by accident and was non-verbal, communicating through facial expressions. The DON stated that nurses were expected to respond immediately and validated the concern.
A resident with a Foley catheter and diagnoses including obstructive/reflux uropathy, bladder dysfunction, cognitive communication deficit, and dementia had the catheter found on the floor after it was apparently pulled out. An LPN documented the event and told the morning nurse, but did not notify the provider or the RP. The record did not show provider notification, and the DON stated the expectation was to notify the provider and family member when a Foley comes out.
The facility failed to provide written bed-hold policy notices to residents or their representatives when residents were transferred to the hospital. Surveyors found no documentation for three residents, and staff including an LPN, Unit Manager, and DON could not produce evidence that the required notice was given or filed in the chart; one resident also stated no copy was provided, though a call about bed-hold payment was later received.
Failure to Hold Quarterly Care Plan Meeting: A resident’s quarterly MDS was completed, but the record had no evidence of an IDT care plan meeting with the resident and/or RP at the time of the quarterly review. The DSS could not provide documentation of a July care plan meeting and confirmed there was no invitation, meeting record, or other evidence of the required quarterly care plan review.
Failure to provide hearing services and ENT follow-up: A resident reported hearing loss and requested an ENT consult, but the chart showed no ENT appointment and no care plan for hearing difficulty. The record documented impacted earwax, Debrox orders, and persistent blockage, while the DON confirmed the ENT visit was not scheduled until after the surveyor raised the concern.
Delayed wound consult implementation resulted in missed wound treatments for two residents. A resident with a Stage 4 sacral wound and another resident with a reopened heel wound had wound NP recommendations documented, but the corresponding wound care orders were not started until days later, leaving gaps in treatment. The DON stated wound treatment recommendations are expected to be completed the same day they are received.
A resident with a Foley catheter, urinary retention, and dementia experienced catheter disconnection and delayed, inconsistent management by nursing staff. An LPN initially found the catheter out, but documentation was incomplete and staff gave conflicting accounts of who attempted reinsertion and when. A larger catheter was inserted without a documented order, the resident had abdominal distension and no drainage, and an NP later found more than 999 mL retained with immediate urine flow after advancing the catheter.
Failure to monitor and document pain management for a resident with gout, a sacral wound, BPH, and CKD3. The care plan called for pain to be assessed and recorded every shift, and a Tylenol order was in place for mild pain on a 0-10 scale, but MAR review showed no evidence of routine pain monitoring or Tylenol administration for pain. The resident reported daily knee pain, and the DON confirmed the resident’s pain was not being assessed daily per the care plan and there was no record of pain medication being given for knee pain.
The facility failed to ensure controlled substance medications were accurately monitored on 1 of 9 med carts. On the 1 [NAME] unit, the controlled substance logbook had gaps in the sign-on/sign-off section, with missing nurse signatures for multiple shift changes and no documented two-nurse count verification of the remaining controlled substances. An LPN was shown the missing entries and acknowledged the gaps.
Failure to timely address a pharmacist MRR recommendation: A resident with Bipolar Disorder was receiving risperidone for mood, and the consultant pharmacist recommended evaluating the medication for mood/psychosis and obtaining a psych consult. Surveyors could not find an order or psych consult note in the resident’s chart, and the DON confirmed the consult was not completed within the recommended timeframe. The completed recommendation was kept in a binder in the DON’s office rather than in the medical record.
Medication administration errors were identified when nursing staff failed to give insulin to two residents within the ordered time window. Two of 26 observed medications were administered more than 1 hour after the scheduled 9:00 AM time, with one resident receiving insulin at 11:11 AM and another at 11:12 AM. The findings were cited during the survey after the meds were observed outside the permitted administration window.
Medication refrigerator temperature was not maintained properly in one med room. Surveyors observed the freezer compartment about three-quarters full of solid ice, and the thermometer read 28 degrees Fahrenheit. The Unit Manager acknowledged the issue and stated the thermometer may have been too close to the freezer.
Failure to monitor and track antibiotic use: A resident with MRSA wounds was receiving IV Ceftaroline, but the MAR showed multiple missed doses across several treatment periods and one day when the antibiotic was documented as given four times despite being ordered q8h. The IP stated antibiotic use was reviewed in monthly stewardship and daily clinical meetings, but no concerns had been identified for the resident until the missed and extra doses were reviewed.
A resident’s call bell was repeatedly activating without being pressed and would not turn off, leading staff to enter the room multiple times after the resident said no help was needed. The resident reported the issue had continued for two days, and maintenance later stated a one-man device had been placed on a two-man system, causing the call bell to trigger constantly. The DON was informed of the finding.
Failure to post survey results in a public area. Surveyors found no state inspection results or notices in the lobby or other public areas, and no signs directing residents or visitors to the survey binder. A group of residents said they were unaware of their right to review survey results or where to find them. At the reception desk, the binder was kept behind the desk out of public view, and the DON confirmed it should have been in the lobby with proper signage.
Multiple wheelchairs were found to be unsanitary and in disrepair, including one used by a resident for an outside appointment that contained urine and fecal matter in the cushion. Several other wheelchairs had cracked, ripped, or missing armrests, with exposed foam and inadequate support. Housekeeping staff confirmed there was no prior cleaning or maintenance schedule for wheelchairs or their cushions.
Facility staff failed to accurately code MDS assessments for several residents, resulting in omissions and errors related to significant weight loss, falls, pressure ulcers, wounds, and the administration of medications such as hypoglycemics, antibiotics, anticoagulants, and opioids. These discrepancies were confirmed by MDS coordinators after review of medical records and medication administration records.
A resident with a leg amputation was not provided with their custom-made wheelchair during transport to a medical appointment, resulting in the use of other wheelchairs and repeated repositioning by staff. The facility lost the resident's specially fitted wheelchair on multiple occasions, and staff failed to follow up to ensure the resident had access to the necessary equipment, despite complaints from the resident's family and awareness among facility leadership.
Facility staff failed to promptly notify a physician after a resident with heart failure experienced a sudden and sustained drop in blood pressure, despite repeated attempts to reach the provider and ongoing monitoring. In a separate incident, another resident experienced a significant weight loss over three weeks, but there was no timely notification to the physician, dietician, or family, and the resident was not promptly assessed or discussed in risk meetings.
The facility did not report allegations of abuse, neglect, or injuries of unknown origin to the regulatory agency within the required 2-hour timeframe for three residents. Incidents included a non-verbal resident with a laceration, a resident with a dislocated shoulder and complex medical needs, and an allegation of physical abuse by a GNA. In each case, delays in internal notification and external reporting were confirmed.
Facility staff did not hold or document required quarterly care plan meetings for a resident with dementia, despite completing quarterly MDS assessments. Only one care plan meeting was documented, and there was no record of meetings or summaries for other required quarters, as confirmed by the DON and noted by the resident's representative.
A resident who required extensive two-person assistance for activities of daily living after hip surgery did not receive necessary turning, repositioning, or bowel and bladder care over several day shifts. Documentation showed that assigned GNAs did not perform these essential care tasks, and complaints included inadequate staffing and unanswered call bells.
Facility staff did not implement a consultant's recommendations for an appetite stimulant and protein supplement for a resident with anemia and thyrotoxicosis, and also failed to perform and document neurological assessments at required intervals after an unwitnessed fall for another resident, with inaccuracies in vital sign documentation as confirmed by the DON.
A resident with multiple medical conditions experienced a significant, unrecognized weight loss over a three-week period. Facility staff did not perform weekly weights as recommended, failed to promptly notify the physician or dietician of the weight loss, and delayed assessment and intervention, contrary to facility policy.
Failure to Timely Report Injuries of Unknown Origin to State Authorities
Penalty
Summary
Facility staff failed to timely report injuries of unknown origin for two residents to the State of Maryland's Office of Health Care Quality (OHCQ). For one resident, a family member noticed a contusion on the resident's right upper arm while visiting and reported this skin issue to the assigned Geriatric Nursing Assistant (GNA) at approximately 2:30 PM. The family member asked that the resident not be disturbed because the resident was asleep, and the GNA did not assess the resident at that time. The GNA then unintentionally failed to report the family’s concern or the potential injury to a nurse or any other staff member before leaving for the day. The facility did not become aware of the injury until the family member emailed the Assistant Director of Nursing (ADON) several days later, at which point the injury of unknown origin was reported to OHCQ, resulting in a four-day delay from when the family first identified and reported the potential injury to staff. In a separate incident, another resident was observed by nursing staff with a bruise to the right thigh that was treated and documented as an injury of unknown origin. Nursing staff reported this injury to the Dementia Unit Manager, but the Dementia Unit Manager did not notify the Director of Nursing (DON) or the Administrator on the date the injury was discovered. Administration only became aware of the injury several days later when the Dementia Unit Manager reviewed the nursing documentation and recognized that the injury met criteria for an injury of unknown origin. The injury was then reported to the DON and subsequently to OHCQ, but this delay caused the facility to report the injury to the state agency late. Both incidents were confirmed through staff interviews and review of the facility-reported incident investigations.
Failure to Thoroughly Investigate Abuse Allegation and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse for one resident. An alert and oriented resident with multiple diagnoses and complex medical needs was admitted following an acute hospitalization and later provided the Unit Manager with a handwritten note alleging that on the second day of admission the resident was “beaten up during bath time.” The note did not identify staff or the shift involved. Review of the investigation showed no documentation that the resident was interviewed about the allegation after staff became aware of it. The investigation file also contained an undated typed statement indicating that when social services went to visit the resident about an incident, the resident declined to talk and declined to write a statement, but the document did not identify the author, the social services staff involved, or the specific incident referenced. Further review of the abuse investigation revealed that no interviews were documented with other residents on the unit, despite the allegation of abuse. Instead, statements were obtained from resident representatives for three other residents who were documented as cognitively impaired and not interviewable, with no documentation explaining why residents themselves were not interviewed. Staff interview statements were only obtained from the nurse and GNA on the 7 AM–3 PM shift and the nurse and GNA on the 3 PM–11 PM shift for the date of the alleged incident. There was no documentation of interviews with the nurse and GNA assigned to the resident on the 11 PM–7 AM shift, and no written statement from the Unit Manager who originally received the handwritten abuse allegation from the resident. The deficiency also includes the facility’s failure to thoroughly investigate an injury of unknown source for another resident. This resident, admitted with multiple diagnoses, severe cognitive impairment, and ventilator dependence, displayed a facial grimace when staff moved the right arm during incontinence care, leading to an x-ray that suggested a possible hairline fracture of the right wrist, followed by a later hospital x-ray that showed no fracture. The facility’s investigation contained only three employee statements: from the RN and GNA providing care at the time of the observed grimace, and from a GNA who was not assigned to the resident but assisted with care that day. There was no documentation that staff from preceding shifts or days were interviewed, and no documentation that any residents were interviewed in response to the injury of unknown source.
Failure to Accurately Document Change in Discharge Plan and Appeal
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident in accordance with accepted professional standards. Facility investigative documentation for a facility-reported incident showed that a resident, who was his/her own decision maker, left the facility in the early morning hours without informing staff and later returned home safely. Review of records also showed that the resident had been given a notice of non-coverage indicating the last covered day of the stay and the right to appeal, and the resident signed this notice. Further review of the resident’s medical record revealed a Social Services progress note documenting that the Social Services Assistant received the last covered day notice and that the resident was ready to go home and planned to discharge earlier than originally indicated, with home health to be set up and the resident planning to go home by taxi. In a subsequent interview, the Social Services Assistant stated that after providing the notice, she contacted a family member involved in the resident’s care, who expressed a desire to appeal the discharge and felt the resident needed more time. The Social Services Assistant reported that she informed staff there would be an appeal and that the resident would be staying, and she later told the resident about the family member’s wish for the resident to remain. She confirmed that she did not document this updated discharge plan and appeal information in the resident’s medical record, resulting in an incomplete and inaccurate record for the resident.
Unlabeled Stored Food Items in Kitchen
Penalty
Summary
Food items stored in the kitchen were found without required labeling during a tour of the walk-in cooler, deep freezer, and refrigerator areas. In the walk-in cooler, a box of blue berries, a box of oranges, and Biscolli cheese were observed without received-by dates or used-by dates as applicable. In the deep freezer, a box of chicken thighs was not labeled, and two logs of Sysco Fire River farm ground beef on a shelf and one log on a cart were also without labels. During the same survey, additional unlabeled food items were observed, including a box of tortilla, a single bag of hoagies, broccoli in a bag in the refrigerator, a bag of cube-like sausages, three lamb patties in a bag, and seven sticks of gold and sweet butter removed from an original container. A Dietary Aide stated that unlabeled items should have had a received-by date label and opened items should have had a used-by date label. The Regional Director of Dining Services was made aware of the concerns during the follow-up tour, and the Food Service Director later stated that staff would be re-educated on proper labeling of food items.
Unresolved Resident Grievances and Lack of Grievance Process Information
Penalty
Summary
The facility failed to honor residents’ right to voice grievances without discrimination or reprisal and failed to establish and use a grievance process that addressed concerns raised in Resident Council meetings. Review of Resident Council minutes from January 2025 through July 2025 showed repeated concerns that were not addressed or resolved, including complaints about staff not assisting with toileting, not responding to call lights, impatience during transfers, long call light wait times on weekends and nights, poor bedside manner, loud shift changes, housekeeping concerns, inconsistent room temperatures, clogged toilets, staffing shortages in Activities, and missing clothing and supplies. The minutes also showed no evidence that residents were informed of resolutions to these concerns. During the surveyor-held Resident Council meeting with seven residents present, residents reported that concerns raised in prior meetings had still not been addressed. One resident stated call lights were not answered for over an hour, another reported missing clothing and broken glasses with no resolution, and another said night staff were loud, concerns were not rectified, and clothing often went missing. A resident also agreed that slow call light response was a continuing problem. Review of five Resident Concern forms from a second July Resident Council meeting showed that four forms lacked a resident identifier, one stated it would be addressed at the next scheduled meeting, and none showed that a resolution had been communicated to the resident. Survey observations and staff interviews showed that grievance information was not clearly available to residents or staff. No visible postings were observed explaining how to file a grievance or identifying the grievance officer. Staff gave inconsistent descriptions of where forms were kept, and one staff member had to ask another where the forms were located. The DON stated the Administrator and Social Worker served as grievance officers, while the Social Worker said grievance information was included in the admission packet. However, review of the admission packet found no written explanation of the grievance process for residents or families, and the Administrator stated that residents learned about grievances through staff, ambassadors, family members, or the compliance line. The Administrator also stated compliance line complaints were not formally logged and residents/families were notified by phone of resolutions.
Failure to Complete and Provide Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan (BLCP) was completed within 48 hours of admission and failed to provide a BLCP summary, including a current medication list, to the resident and/or resident representative for 3 residents reviewed: Resident #54, Resident #160, and Resident #2. Review of the medical records for each of these residents showed admission to the facility, but further review failed to reveal a BLCP in the record. During interviews on 8/1/25 and 8/5/25, the Director of Social Services and the Regional Director of Social Work stated that the BLCP is initiated by nursing and that the resident and family receive a printed care plan during the Care Navigation Meeting and Initial Guide. When the surveyor requested the BLCP for Resident #160, Resident #54, and Resident #2, along with evidence that it had been provided to the resident or resident representative, the Director of Social Services stated on 8/5/25 that she did not have the requested documentation.
Unsafe lift use and inadequate supervision of cognitively impaired residents
Penalty
Summary
The facility failed to ensure residents were free from accidents by not properly educating staff on how to operate a Hoyer lift and by not maintaining supervision of residents from the locked dementia unit. One resident with a BIMS score of 0 and low cognitive functioning was being transferred in a Hoyer lift when the sling was too large and the resident’s chin tucked into the chest, blocking the airway. The resident turned purple, staff could not lower the lift right away, and the resident became unresponsive and pulseless before CPR and bagging were started. Interviews and the facility’s investigation showed that a GNA who had never used the lift before operated it, the family assisted with the transfer, and staff were unsure which button to press and whether the sling was the correct size. A second resident with dementia and two certificates of incapacity was observed off the locked dementia unit, unattended, sitting in a wheelchair by the elevator. The resident was not accompanied by staff and stated he/she was going to dialysis. The ADON acknowledged that residents from the locked unit should not be unattended and should not go to dialysis independently. The dialysis transporter later stated she had left the resident in the hallway off the unit while she went to pick up another resident, explaining that she normally did this to transport two residents at once. A third resident with cognitive impairment and psychosis was observed at the nurses’ station reaching over the desk, opening a drawer, and rummaging through its contents while staff did not intervene. The drawer contained batteries, a lanyard, and plastic cutlery. The ADON stated it was not the expectation for residents to access the nurses’ station drawer and acknowledged that the items could be a safety risk. The resident had two certificates of incapacity related to psychosis and cognitive impairment.
Missing emergency clamps for residents receiving dialysis
Penalty
Summary
Safe, appropriate dialysis care/services were not provided because facility staff failed to keep emergency clamps at the bedside for residents receiving dialysis who had orders for an AV fistula clamp to be kept in the room at all times. Review of the medical record for one resident showed dialysis treatment on Mondays, Wednesdays, and Fridays, with orders to monitor the left arm AV fistula access site for signs and symptoms of infection, drainage, bruising, and bleeding every shift and as clinically indicated, and to keep a clamp at the bedside at all times. During room observations, the surveyor did not find a clamp in that resident's room, and the resident stated there was no clamp in the room. Staff confirmed that an emergency clamp should be in the room but could not locate one. The DON also stated that residents on dialysis should have a clamp in the room. Additional room checks found no clamp in the rooms of four other residents receiving dialysis who also had orders to keep a clamp at bedside at all times.
Infection Control Failures in Laundry Handling and Precaution Signage
Penalty
Summary
The facility failed to follow infection control practices and guidelines to prevent the development and transmission of infection and disease. During a tour of the laundry room, four full bins were observed containing used linens and residents' clothing that were not bagged in plastic bags before transfer to the laundry room. The Housekeeping Director confirmed that contaminated linens and clothing should be placed in plastic bags and tied before being moved, and stated that the items observed were not properly bagged. The Infection Preventionist also confirmed that contaminated linens and clothing should be bagged before transfer and validated the concern after the observation was shared. The facility also failed to appropriately manage precaution signage for residents on Enhanced Barrier Precautions. During a unit tour, two residents who were on the EBP order list did not have precaution signage posted on their room doors. Record review showed that one resident had an EBP order for hemodialysis access and the other had an EBP order for tracheostomy and gastrostomy. The DON stated that residents' precaution status should be posted by the Infection Preventionist, while the Infection Preventionist stated that the unit manager posted contact precaution signage. Later, the Infection Preventionist and Regional Infection Preventionist gave different explanations for the missing signs, stating that one sign had fallen off and the other was about to be replaced after contact precautions ended, but no staff were observed managing the signs during the surveyor's time on the unit.
Incomplete Annual GNA In-Service Training
Penalty
Summary
The facility failed to have a process in place to ensure Geriatric Nursing Assistance (GNA) received at least 12 hours of annual in-service training. Review of employee training files showed that GNA #53 received only 1.73 hours of training in 2024, GNA #54 received 11.53 hours over 2023 and 2024, and GNA #55 received 6.43 hours over 2022 and 2023. During interviews, the Human Resource Director stated that the annual 12-hour training for GNAs is completed through Relias upon hire and then annually, while the Staff Developer/Educator stated weekly reports are run and staff are called if tasks are not completed, with annual training expected to be finished before the end of the year and checked again in November. The Staff Developer/Educator later confirmed that staff members #53, #54, and #55 had not completed the required 12-hour training, and this was communicated to the DON.
Delayed Response to Resident Call Bell
Penalty
Summary
The facility failed to attend to and answer call bells in a timely manner for a dependent resident. During a tour of the first floor on 8/08/25, a call bell screen on the 1 [NAME] unit showed that a call bell from a room had been active for 113 minutes. When the surveyor asked a nurse about the screen, she confirmed the call had been on for 113 minutes and stated that someone was working on fixing something in that room. The surveyor immediately checked the room and found only Resident #149 lying in bed, with no other staff present and no evidence of a construction procedure. The resident was vulnerable and had a tracheostomy and tube feeding. A GNA later entered the room and stated the resident had pushed the call bell by accident and did not need help, adding that he communicated with the resident through facial expressions because the resident was non-verbal and that the bell may have been pushed under the resident's elbow. The DON confirmed that the facility expected nurses to respond to the call bell immediately and validated the concern.
Failure to Notify Provider and RP After Foley Catheter Dislodgement
Penalty
Summary
The facility failed to notify the resident's physician and/or responsible party after an accident/change in condition involving an indwelling urinary catheter for one resident. The resident was admitted with a Foley catheter and diagnoses including obstructive and reflux uropathy, neuromuscular dysfunction of the bladder, other specified disorders of the bladder, cognitive communication deficit, and unspecified dementia. The care plan identified the resident as having an indwelling urinary catheter related to urinary retention and included monitoring and reporting pain, discomfort, and signs and symptoms of UTI, with abnormal findings to be reported to the practitioner. According to staff interview, an LPN emptied the Foley catheter around 6:00 AM and later found the resident's Foley catheter on the floor after changing another bed in the room. The LPN stated the resident had voided, documented the urine amount, and told the morning nurse that the resident had pulled out the Foley, but did not notify any provider or the resident's RP. The medical record contained a progress note documenting the Foley was intact and draining well earlier that morning, but it did not show that a provider was notified after the catheter came out. The DON stated the expectation was to notify the provider and family member when a Foley came out, and the facility policy stated to notify the physician of abnormalities such as pain, bleeding, or obstruction.
Failure to Provide Bed-Hold Policy Notice During Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents or their representatives when residents were transferred to an acute care facility. This deficiency was identified for three residents who had been transferred from the facility to a hospital or acute care setting, and surveyors reviewed medical records and interviewed staff to verify whether the required documentation had been provided. For Resident #154, the record showed the resident was found unresponsive, CPR was initiated, and 911 was called before EMTs took over care and transported the resident, but no bed-hold policy documentation was found in the chart. An LPN stated that transfer paperwork was given to EMTs and was not sure whether the bed-hold policy was included, while the DON stated the policy should be part of the electronic transfer documentation and filed in the chart, but later confirmed the record did not contain it. For Resident #66, the record showed transfer to a hospital with no bed-hold notice in the paper or electronic record; the Unit Manager stated a copy should be given to the resident or representative and placed in the chart, but could not provide one, and the resident stated no copy was given, though a call was received during the hospital stay about payment for bed hold. For Resident #8, the clinical record showed transfer to the hospital, but surveyors could not find evidence that the resident or family received the bed-hold policy or a notice stating the reason for transfer, and the DON acknowledged that neither document was provided.
Failure to Hold Quarterly Care Plan Meeting
Penalty
Summary
The facility failed to hold interdisciplinary care plan meetings at the time of the quarterly revision of the care plan for Resident #54. The resident had a quarterly MDS assessment completed on 7/23/25, but the medical record contained no evidence that a care plan meeting was held with the resident and/or responsible party and the interdisciplinary team around the time of that quarterly assessment or care plan revision. During record review on 8/4/25, the surveyor also reviewed the facility policy, which stated that the interdisciplinary team reviews and updates the care plan at least quarterly in conjunction with the required quarterly MDS assessment. In interviews on 8/5/25, the Director of Social Services was unable to provide evidence of a July 2025 care plan meeting for Resident #54, stated that the meeting should have been held in July 2025, and confirmed there was no invitation, care plan meeting, or other evidence or documentation from July 2025.
Failure to Provide Hearing Services and ENT Follow-Up
Penalty
Summary
The facility failed to provide services to maintain hearing for Resident #3, who reported losing hearing and requested an ENT consultation about a month before the survey interview. During the medical record review, there was no indication of an ENT appointment and no care plan addressing the resident’s hearing difficulties. The resident stated that a nurse told him/her the insurance would not cover the ENT visit. The record showed that on 06/30/2025, the Nurse Practitioner assessed the resident for left ear complaints and a hearing change, noting dark brown, dry, impacted earwax in the left ear. Debrox ear drops were ordered on 07/02/2025 for left ear wax buildup, but the medication was not available at first and the physician was notified to administer it when available and reschedule the therapy. A later physician note stated the eardrops had not relieved the blockage yet, and another order was written for Debrox for both ears. During interview, the DON confirmed that an ENT appointment would require a physician order and scheduling by the Unit Clerk, and it was verified that no follow-up or scheduled ENT appointment had been made despite the resident’s request until after the surveyor raised the concern.
Delayed Wound Consult Implementation Led to Missed Treatments
Penalty
Summary
The facility failed to implement wound consult recommendations in a timely manner, resulting in missed wound treatments for 2 of 7 residents reviewed for pressure ulcer/injury care. For Resident #63, a wound NP documented a Stage 4 sacral wound and recommended daily cleansing with wound cleanser, Dakins-moistened fluffed gauze, Zinc Oxide Paste to the periwound and base, secured with bordered foam and an ABD pad. The TAR showed a prior physician order for sacral wound care that was blank on 02/13/2025, and the wound NP’s recommended treatment did not start until 02/14/2025, three days after the recommendation was documented, leaving the resident without wound care on 02/13/2025. For Resident #127, a wound NP documented a reopened left heel wound and recommended daily cleansing with wound cleanser, calcium alginate to the wound base, and bordered foam with changes as needed. The TAR showed a physician order for left heel care that was blank on the day shift of 06/25/2025 and marked with an X on the evening shift, and the wound care order reflecting the NP’s recommendation did not begin until 06/26/2025, two days after the recommendation. During interview, the DON stated the wound NP discusses recommended treatments with the Unit Manager and/or charge nurse and sends them to the PCP for approval, and that this process is expected to be completed the same day the recommendation is received.
Inadequate Foley Catheter Management and Documentation
Penalty
Summary
The facility failed to provide appropriate and sufficient services, treatment, and care for a resident with an indwelling urinary catheter. Resident #160 was admitted with a Foley catheter and diagnoses including obstructive and reflux uropathy, neuromuscular dysfunction of the bladder, cognitive communication deficit, and unspecified dementia. The care plan directed staff to monitor and report pain or discomfort related to the catheter and to monitor for signs and symptoms of UTI, including no output and changes in condition. The resident’s Foley catheter was found detached in bed, and staff could not explain how it came off. The night nurse reported that the catheter was on the floor and that the resident had voided, but there was no documentation from that nurse in the medical record about the event, the urine output, or any related changes in condition. The day nurse later reported that he was told the catheter had come out and that he attempted to reinsert it, but he initially stated he did not insert a catheter during his shift and later clarified that he had tried to place one but could not fully insert it and then called the NP. The record also showed an SBAR note stating that a 14 Fr catheter had been on admission, that staff could not find it, and that a 16 Fr catheter was inserted but did not work. The evening nurse documented that the resident refused twice before the Foley was replaced, but there was no documentation of the first two insertion attempts. The DON stated there was no physician order for a 16 Fr Foley catheter. The NP later stated he was only contacted once, did not document the call, and said no voiding trial had actually been ordered. Another NP who responded to the room stated the resident had abdominal distension, a bladder scan greater than 999 mL, and immediate relief after the catheter was advanced and urine began flowing. The resident’s responsible party stated the resident was feeling bad, was not voiding on his own, and nearly had to go to the hospital because the catheter was not working properly.
Failure to Monitor and Document Pain Management
Penalty
Summary
Safe, appropriate pain management was not provided for Resident #13. The resident had diagnoses including gout, a sacral wound, BPH, and CKD stage 3, and the care plan dated 11/09/2023 identified pain as an active focus with interventions to anticipate pain relief, monitor and record pain every shift and as needed, and notify the physician if interventions were unsuccessful or if there was a significant change from the resident’s past pain experience. A physician order dated 07/05/2025 directed Tylenol every 6 hours as needed for mild pain on a 1-3 pain scale. Review of the MARs for June, July, and August 2025 showed no evidence that pain was monitored or recorded every shift, and Tylenol was not documented as having been administered for pain. There were no orders for additional pain medications for pain levels above 3. During interview, the resident reported daily knee pain and stated that staff gives Tylenol and it does not help much. The DON stated that the facility’s pain monitoring procedure uses a 0-10 pain scale and that pain levels should be documented with medication administration and on the MAR, but confirmed that the resident’s pain level was not being assessed daily per the care plan and there was no indication or record of pain medication being given for knee pain.
Controlled Substance Count Log Missing Shift Signatures
Penalty
Summary
The facility failed to ensure controlled substance medications were monitored for accuracy on 1 of 9 medication carts. On the 1 [NAME] unit medication cart, the controlled substance logbook showed gaps in the sign-on/sign-off section where two nursing staff were supposed to verify and count each resident’s controlled substance medications against the remaining pills, capsules, and other dosage forms. The logbook had no signatures for nurses starting or ending shifts on multiple occasions, including day shift on 6/2/25, day shift on 6/12/25, evening shift on 6/16/25, day shift on 6/18/25, day shift on 6/21/25, day shift on 6/22/25, day shift on 6/27, and night shift on 7/4/25. Staff #59 was shown the missing signatures in the controlled substance logbook and responded, "Oh, I see."
Failure to Timely Address Pharmacist Medication Review Recommendation
Penalty
Summary
The facility failed to respond in a timely manner to recommendations made by the consulting pharmacist during the monthly medication regimen review. For Resident #125, who had a diagnosis of Bipolar Disorder and was receiving risperidone 1 mg by mouth at bedtime for mood, the consultant pharmacist recommended on 3/9/2025 that the use of Risperdal be evaluated for mood/psychosis. The report was signed by the physician with a written recommendation for a psychiatric consult, but the recommendation was not documented in the resident’s paper chart, and the completed recommendation was kept in a binder in the DON’s office rather than in the medical record. During record review, surveyors could not locate an order or a psychiatrist consultation note in the resident’s medical record. The ADON stated that the pharmacist emailed the MRR to her and the unit managers, that the recommendations were printed and given to unit managers for physician review, and that the physician signed and the copy was placed in a binder in the DON’s office. The DON later stated that the resident was not consulted by a psychiatrist within the time frame of the recommendation and agreed that this was a concern.
Medication Administration Errors Exceeded Allowed Time Window
Penalty
Summary
Medication administration errors were identified when facility nursing staff failed to ensure residents received insulin according to physician's orders. During the medication administration task, 2 of 26 medications observed were administered outside the allowed medication administration window of one hour before or one hour after the scheduled time. Resident #121 received insulin at 11:11 AM instead of the scheduled 9:00 AM administration time, resulting in a delay of one hour and eleven minutes beyond the permitted window. Resident #91 received insulin at 11:12 AM instead of the scheduled 9:00 AM administration time, resulting in a delay of one hour and twelve minutes beyond the permitted window. The findings were identified during the recertification/complaint survey and were shared with facility administration at the exit conference on 8/8/25.
Medication Refrigerator Temperature Not Maintained
Penalty
Summary
The facility failed to ensure a medication refrigerator maintained proper temperature in one of the two medication rooms observed during the medication administration task. During survey observation of the medication refrigerator on one west, the freezer compartment was approximately three-quarters filled with a solid piece of ice, and the thermometer read 28 degrees Fahrenheit. When the Unit Manager was shown the condition of the refrigerator and the thermometer reading, the Unit Manager stated, "Oh, I have to defrost" and later said, "Probably because it was so close to the freezer. I'll move it or get another thermometer."
Failure to Monitor and Track Antibiotic Use
Penalty
Summary
The facility failed to adequately monitor and track residents receiving antibiotics as part of its antibiotic stewardship program. During record review and staff interviews, Resident #11 was identified as receiving Ceftaroline for wounds on the left lower legs with an MRSA infection after hospitalization, with the discharge record indicating Infectious Disease recommended continuing IV Ceftaroline 200 mg until 8/04/25. The MAR showed multiple missed doses during the resident’s antibiotic courses, including missed doses on 7/01/25 and 7/02/25 at 2 PM, missed night doses on 7/04/25 and 7/07/25, and all three doses not given on 7/19/25. The MAR also documented that on 7/23/25 the resident received four doses of Ceftaroline in one day, including doses at 0000, 0600, 1400, and 2200, even though the order was for every 8 hours. During interviews, the Infection Preventionist stated that antibiotic use was reviewed in monthly stewardship and daily clinical meetings and that no concerns had been noted for this resident. When the missed doses and the dosing pattern were reviewed, the Infection Preventionist acknowledged that the antibiotic should not have been missed and verified that Ceftaroline ordered three times per day should not have been given four times that day.
Call Bell Malfunction in Resident Room
Penalty
Summary
A working call system was not maintained in a resident’s bathroom and bathing area, as staff failed to ensure the call system operated correctly for the room. During an interview and observation, Resident #85 stated that the call bell was alerting staff even though the resident had not pressed it and that it would not turn off. The resident reported that the problem had been occurring for two days, causing staff to repeatedly enter the room, ask what assistance was needed, and then leave after being told nothing was needed, only for the call bell to activate again. A unit manager entered the room during the interview and was told by the resident that no assistance was needed and that the call bell had been coming on by itself and would not turn off. Maintenance staff later stated they had tried to reset the call bell and were unaware it had been going off constantly for two days. He explained that a one-man device had been placed on a two-man system, which caused the call bell to be triggered continuously. The DON was informed of the findings and stated staff had been answering the call bell and she was unaware of any malfunction.
Failure to Post Survey Results in a Public Area
Penalty
Summary
The facility failed to post a notice of the availability of survey results in a prominent, publicly accessible location, and survey results were not visible in the lobby or other public areas during the annual survey. Surveyors observed that no state inspection results or notices were posted, and no signs directed residents or visitors to the location of the survey results. During a group interview, seven residents stated they were unaware of their right to review survey results and did not know where the results were located. At the reception desk, surveyors found no signage for the survey binder, and the receptionist produced the binder from behind the desk, out of public view, while being unsure of any other location. The DON confirmed that the survey binder should have been in the lobby with proper signage and acknowledged that residents were uninformed and the binder was not publicly accessible.
Failure to Maintain Sanitary and Safe Wheelchairs
Penalty
Summary
The facility failed to maintain wheelchairs in a sanitary, comfortable, and well-maintained condition, as evidenced by observations and interviews during a complaint survey. One resident attended a medical appointment in a wheelchair with a cushion that was found to contain urine and fecal matter, emitting a strong odor that had been a source of complaints for months. Upon inspection, the gel pad and pillow cover were visibly soiled, and the family, as well as medical staff at the appointment, were disturbed by the condition. Housekeeping staff confirmed that prior to this incident, there was no established schedule for cleaning or maintaining wheelchairs or their cushions, and the wheelchair in question appeared to have never been cleaned. Further observations revealed multiple wheelchairs across two nursing units in disrepair, including cracked and ripped vinyl on armrests, missing armrests, and exposed foam. Several residents were observed using these damaged wheelchairs, which lacked proper padding and support. The Nursing Home Administrator was made aware of these issues by both staff and family members, confirming the lack of a maintenance process for wheelchairs prior to the incident.
Inaccurate MDS Coding for Resident Assessments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as evidenced by discrepancies between medical records and MDS documentation. For several residents, significant clinical events and treatments were not properly recorded in the MDS. One resident experienced a substantial weight loss and a fall, neither of which were accurately reflected in the corresponding MDS sections. Additionally, the administration of hypoglycemic medications and insulin was omitted from the MDS, while an opioid was incorrectly documented as administered when it was not present in the medication administration record. Another resident was admitted with bilateral heel wounds and received ongoing wound care and antibiotics, but the MDS failed to capture the presence of pressure ulcers, venous ulcers, and related treatments. The same resident's MDS also did not reflect the administration of multiple medications, including insulin, diuretics, opioids, antidepressants, antibiotics, and anticoagulants, despite clear documentation in the medical and treatment records. Similar omissions were found for other residents, where falls, pressure ulcers, and the use of specific medications such as antibiotics and anticoagulants were not accurately coded in the MDS, even though these events and treatments were documented elsewhere in the medical record. In one case, a resident's MDS assessment incorrectly indicated the presence of a pressure ulcer that had already healed, and failed to document the use of antiplatelet, hypoglycemic, and antipsychotic medications that were administered during the assessment period. Interviews with MDS coordinators confirmed the presence of these errors across multiple assessments, indicating a pattern of inaccurate MDS coding that did not align with the residents' actual clinical status and care provided.
Failure to Provide Resident with Custom-Made Wheelchair for Transport
Penalty
Summary
The facility failed to ensure that a custom-made wheelchair was available and provided for a resident with a leg amputation during transport to a medical appointment. Staff statements and interviews revealed that the resident, who typically used a geri chair or remained in bed, was transferred to a standard wheelchair for an appointment, during which the resident began sliding out of the chair. Multiple staff members intervened to reposition the resident and eventually transferred the resident to a high-back wheelchair with a pillow for support. The resident did not report pain or injury during the incident. Further investigation revealed that the resident's custom-made wheelchair, provided by the VA and specifically fitted to accommodate the resident's needs following a leg amputation, had been lost by the facility on more than one occasion. The resident's daughter reported that the resident was repeatedly placed in other residents' wheelchairs for appointments, and that complaints about the missing wheelchair had been made to various staff and administrators. The facility's NHA confirmed that the custom wheelchair could not be located and acknowledged that there was no follow-up by staff to ensure the resident had access to the appropriate equipment.
Failure to Timely Notify Physician and Family of Change in Condition and Significant Weight Loss
Penalty
Summary
Facility staff failed to notify a resident's physician in a timely manner following a significant change in condition. One resident, admitted with heart failure, experienced a sudden drop in blood pressure. Nursing notes documented that the resident's blood pressure fell to 70/54 and continued to decline over several hours. Despite repeated attempts to page the provider, there was no response, and the physician was not notified promptly. The family was present and refused hospital transfer, but the facility did not escalate the situation to the Medical Director as expected when the primary physician could not be reached. In another case, a resident experienced a significant weight loss of 25.8 lbs (20%) over three weeks. The medical record did not show timely notification to the physician, dietician, or family when the weight loss was identified. The dietician did not assess the resident until 11 days after the weight loss was documented, and the resident was not evaluated in weekly risk meetings until 13 days later. Facility policy required prompt notification of significant changes in condition, but this was not followed in these instances.
Failure to Timely Report Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe for three residents. In one case, a non-verbal, cognitively impaired resident was found with a laceration to the right thumb, but the incident was not documented or reported by the LPN on duty, and facility administration only became aware the following day. The self-report to OHCQ was sent more than 24 hours after the injury was discovered. In another instance, a resident with multiple complex medical conditions, including tracheostomy, G-tube, diabetes, hemiplegia, and ventilator dependence, was found to have a dislocated shoulder. The injury was confirmed, but the report to OHCQ was not made until the following day, exceeding the 2-hour reporting requirement. A third incident involved an allegation of physical abuse by a GNA, reported by a resident's spouse. The DON was not notified until the next morning, and the initial report to OHCQ was sent several hours after the required timeframe. Documentation from staff revealed inconsistencies in awareness and reporting of the alleged abuse. In all three cases, the DON confirmed the findings of late reporting during interviews, although the DON was not employed at the facility at the time of the incidents.
Failure to Hold and Document Required Quarterly Care Plan Meetings
Penalty
Summary
Facility staff failed to conduct quarterly care plan meetings for a resident diagnosed with dementia, as required following comprehensive and quarterly MDS assessments. The medical record review showed that while quarterly MDS assessments were completed, there was only documentation of a care plan meeting in April and a scheduled meeting in September, with no evidence of meetings in January and July. Additionally, there was no documentation summarizing or detailing what was discussed during the April and September care plan meetings. The resident's representative expressed concerns about the facility's lack of communication. The Director of Nursing confirmed that the required quarterly care plan meetings were not held for the resident in January and July, and that documentation of the content of the meetings that did occur was missing from the medical record.
Failure to Provide Required ADL Assistance and Repositioning
Penalty
Summary
A deficiency was identified when a resident, admitted for rehabilitation following surgery for a periprosthetic hip fracture and requiring extensive assistance with two-person support for transfers, bed mobility, dressing, toileting, and general hygiene, did not receive necessary care on multiple day shifts. Documentation review revealed that the assigned geriatric nursing assistant (GNA) failed to perform required turning, repositioning, and bowel and bladder care for the resident over three consecutive days. Additionally, complaints were made regarding inadequate staffing, lack of resident changing, turning, repositioning, and unanswered call bells. These findings were based on direct review of the resident's medical record and GNA documentation.
Failure to Follow Consultant Recommendations and Neuro Check Protocols
Penalty
Summary
Facility staff failed to provide care in accordance with consultant recommendations for a resident admitted with anemia and thyrotoxicosis. The resident was evaluated by a consultant who recommended starting an appetite stimulant and a prosource protein supplement due to poor appetite and low albumin levels. Despite these recommendations, the staff did not initiate either intervention before the resident was discharged from the facility. The Director of Nursing confirmed that these recommendations were not addressed. Additionally, staff did not properly perform and document neurological assessments following an unwitnessed fall for another resident. According to facility policy, neuro checks should be completed at specific intervals after such an event. However, the medical record showed that neuro checks were not performed or documented at the required times, and some entries included inaccurate or reused vital signs. The Director of Nursing confirmed that neuro checks were completed at incorrect intervals and with inaccuracies.
Failure to Recognize and Respond to Significant Resident Weight Loss
Penalty
Summary
Facility staff failed to recognize and respond to significant weight loss in a resident admitted for comprehensive rehabilitation with multiple diagnoses, including cerebral infarction, hypertension, type 2 diabetes with hyperglycemia, and a sacral wound. Upon admission, the resident's weight was documented as 128 lbs, a notable decrease from the ideal body weight of 154 lbs. Despite a dietician's recommendation for weekly weights and monitoring due to malnutrition risk, weekly weights were not performed after admission. The next recorded weight, taken three weeks later, showed a further drop to 102.2 lbs, representing a 20% loss. There was no evidence that the physician, dietician, or family were notified of this significant weight loss as required by facility policy. Additionally, the dietician did not assess the resident until 11 days after the documented weight loss, and the resident was not discussed in weekly risk meetings until 13 days after the weight loss was identified. The facility's policy required immediate notification of the dietician in writing for significant weight changes, but this was not followed. Interviews with the physician confirmed the expectation for prompt notification in such cases, which did not occur.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,082 citations issued within 25 miles in the last 12 months — including the 11 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sterling Care Rockville Nursing | 0.6 mi | ★★★★★ | 8 | 0 |
| The Village At Rockville | 1.2 mi | ★★★★★ | 25 | 0 |
| Shady Grove Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 4 | 0 |
| Potomac Valley Rehabilitation And Healthcare | 1.4 mi | ★★★★★ | 3 | 0 |
| Ingleside At King Farm | 1.6 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.