Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Complete Care At Hyattsville during CMS and state inspections, most recent first.
A resident with a Stage 4 sacral pressure ulcer and severe dementia was not repositioned every two hours as ordered by the physician and outlined in the care plan. Over multiple observations on consecutive days, the resident was repeatedly found in the same or similar supine positions, sometimes without a wedge, with no staff seen providing turning or repositioning during these periods. Staff interviews with LPNs, GNAs, and the ADON confirmed that facility protocol required rounding and repositioning every two hours using a badge clock system, and that non-ambulatory residents were expected to be turned, but these expectations were not met for this resident.
Surveyors found that tracheostomy tubing for three residents was repeatedly observed resting on or touching the floor while connected to their airway, without staff intervention. The affected residents had significant neurologic injuries and required ongoing tracheostomy care. The Infection Preventionist acknowledged that tubing should not contact the floor due to contamination risk and that residents were immunocompromised. An LPN stated that rounds are done three times per shift to check tracheostomy residents and that items touching the floor should be replaced with clean ones, while the ADON confirmed nothing should be on the floor but could not explain how tubing was consistently kept off the floor.
The facility failed to preserve resident dignity for multiple residents. Staff entered rooms without knocking, introducing themselves, or asking permission, a resident’s Foley bag was repeatedly observed on the floor without a privacy cover, and an LPN later attached it to a wheelchair without privacy protection. During medication passes, an LPN and an RN administered multiple meds to several residents without informing them what was being given.
Improper Storage of Opened Food Items in Walk-In Freezer: During a kitchen tour, the surveyor and CDM observed opened and unlabeled food items in the walk-in freezer, including pizza dough, tortilla chips, hamburger patties, and French toast. The CDM later confirmed the facility’s food storage policy requires opened packages to be securely closed and labeled with an open date.
The facility failed to consistently follow infection control and PPE practices. A resident on contact and droplet precautions was entered by a GNA without a gown, gloves, or N95, another resident’s Foley bag was repeatedly observed lying on the floor, a GNA cleaned a resident with mucus without proper PPE, an RN reused a shared BP cuff without sanitizing it between residents, linens in the laundry room touched the floor while being folded, and a resident with chronic respiratory failure and ESRD had a nebulizer machine on the floor beside the bed.
Missed Quarterly Care Plan Meetings and Delayed Care Plan Revisions: The facility failed to hold required quarterly care plan meetings and to timely review and revise care plans for several residents. Records showed missed or delayed care conferences for multiple residents, and one resident with repeated falls had no evidence of a care plan update after a fall despite the DON stating interventions were expected to be revised after each incident.
Delayed call bell response: A resident who was fully dependent on staff reported that call bells were answered very slowly and asked for the door to be left partly open so the resident could call out for help. The surveyor observed the resident press the call bell while mucus was dripping from the resident's face; several staff, including the UM, walked past without responding, and the call was not answered for 31 minutes. A GNA later cleaned the resident and an RN then assessed the resident after the resident said he or she did not feel well.
A resident reported not receiving showers despite requesting them, and the family member stated showers had not been offered. The care plan reflected refusal of showers, but the ADL task record did not show any refusal, and the resident had no active physician order for showers when reviewed. The DON stated residents are normally scheduled for two showers per week unless contraindicated and confirmed there was no documentation supporting a shower refusal.
A resident with anoxic brain damage and ESRD had a MOLST on file with verbal consent from the responsible representative for CPR, but the record did not show an Advance Directive or documentation that it was discussed with the resident and/or responsible representative. Social Services assessments also indicated that information on Advance Directives was not provided, and the SSD confirmed the record review findings.
The facility failed to ensure the Ombudsman was notified of resident transfers and discharges for two residents who were sent to a local hospital, including one resident who had a medical emergency. During the survey, the NHA provided an email sent only after the surveyor requested proof of notification, and the SSD stated he had not notified the Ombudsman of transfers and discharges since March 2024.
Inaccurate MDS coding was found for two residents. One resident receiving hospice services was later coded as not receiving hospice care on a quarterly MDS, and an MDS mgr confirmed it was an oversight. Another resident was incorrectly coded as having an ostomy in the MDS despite no ostomy being documented in the chart, and the MDS mgr confirmed the item was inaccurately checked.
Failure to provide BCP summaries to residents or their reps was identified for 2 residents. One resident was ventilator dependent with Chronic Respiratory Failure and Anoxic Brain, and another resident was his/her own RP. Record review found no evidence that either resident's BCP was discussed with them or that a copy, including the current med list, was provided after admission.
A resident with schizoaffective disorder did not have a care plan for that diagnosis. During the survey, the surveyor and DON reviewed the resident’s care plan and the DON confirmed the omission, stating that a care plan with interventions would be added.
A resident who had been certified by 2 physicians as unable to understand or sign documents was still asked to sign facility authorization forms, including a bed hold authorization and an authorization to record. The admission coordinator later stated she had the resident sign the forms to close them out even though she understood the resident lacked capacity, and the NHA acknowledged the concern.
Failure to provide daily oral care to a dependent resident. A resident documented as dependent for oral hygiene was observed multiple times with food particles on the teeth, and the resident’s representative said the mouth care was not being done adequately. The assigned GNA stated oral care was not provided on one shift because the resident was asleep, while the UM confirmed daily brushing was expected even if the resident slept for extended periods.
Failure to provide ordered pressure ulcer treatment. A resident with multiple pressure injuries, including a sacral ulcer that had worsened to stage 4, stated that the nurse did not have Dakins to cleanse the wound. An LPN confirmed Dakins was not used because it was not available and said she used a different wound cleanser instead of the ordered NSS, Santyl, and 1/4 strength Dakin's dressing regimen.
Respiratory care was not provided appropriately when oxygen tubing was left unlabeled and oxygen storage procedures were not followed for two residents. One resident with Chronic Respiratory Failure with Hypoxia and ESRD was observed using O2 via nasal cannula, and the tubing was not dated or labeled for replacement. The resident’s record included an order for O2 at 2 L/min PRN for SOB, but no order to change the tubing, despite facility policy requiring weekly tubing and mask/cannula changes.
Failure to complete annual GNA Performance Reviews. Review of employee files found that one GNA had a review that was overdue and still incomplete at the time of survey, even though the DON stated reviews are done annually and as needed. The DON later provided a completed review after the surveyor's intervention.
A resident’s medications were left unattended on top of a medication cart during med administration. An RN entered the room with water and crushed meds in applesauce, then left cups of lacosamide, valproate acid, and levETIRAcetam on the cart. The RN acknowledged the meds should not have been left unattended and stated facility policy requires meds to be kept inside the med cart when unattended; the DON was later notified of the observation.
Call bells were not within reach for two residents during observations. One resident’s call bell was lying on the floor behind the bed while the resident was in bed and later in a recliner, and another resident’s call bell was also found on the floor behind the bed and later out of reach near the wall while the resident was in a wheelchair. The DON and a UM both agreed the call bells were not accessible, and the facility policy stated call lights should be available at the bedside, toilet, and bathing facility and within reach of the resident.
Leaking Corroded Pipe in Administrative Hallway: Surveyors observed water dripping from a ceiling pipe into bins in an admin hallway between the DON's office and the Conference Room, with black plastic bags, caution tape, and cones blocking the area. The ceiling tiles were loose, mismatched, and stained. The Administrator and Maintenance Director stated the pipe was corroded and leaking, and records showed the issue was being monitored, but there was no documentation that the pipe itself had been repaired or replaced.
Failure to Complete Required Annual GNA Inservice Training: Two GNAs did not complete the required 12 hours of annual inservice training. Record review showed one GNA hired in 2022 and another hired in 2015 lacked the required training hours, and the DON confirmed the records. Staff Development said training was provided through Relias, but one employee did not receive a system-generated schedule and the other did not complete scheduled inservice.
Inaccurate medical records were found for two residents. One resident who was NPO and received meds via G-tube had atorvastatin documented on the MAR as given by mouth, while a second resident’s PRN Tylenol given after a fall was not signed on the MAR despite a progress note documenting administration. The DON acknowledged the documentation errors.
Failure to Reposition Resident as Ordered for Pressure Ulcer Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide pressure ulcer prevention care in accordance with physician orders and the resident’s care plan, specifically by not repositioning a resident every two hours. Surveyor observations over multiple days showed that Resident #8, who was care planned and ordered to be turned and repositioned every two hours, remained in the same or similar positions for extended periods without evidence of repositioning. On one day, the resident was first observed lying on the right side facing the wall, and later that day was observed supine with a wedge at the feet. The following day, the resident was observed supine without a wedge in the morning and again in the early afternoon and mid-afternoon in the same position, with no staff observed providing repositioning assistance during these intervals. Record review showed that Resident #8 was admitted with diagnoses including a Stage 4 pressure ulcer of the sacral region, severe unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a history of TIA and cerebral infarction without residual deficits. The care plan, initiated in early September and revised in early October, included pressure injury preventive interventions requiring turning and repositioning every two hours. Physician orders dated mid-August directed staff to assist and/or encourage the resident to turn and position every two hours for pressure relief each shift. Multiple LPNs and GNAs, as well as the ADON, confirmed in interviews that facility protocol and expectations were to round and reposition residents every two hours, using a clock on staff badges as a guide, and that residents unable to move themselves were supposed to be turned. Despite this, the observations of Resident #8 demonstrated that the ordered and care-planned repositioning was not carried out as required.
Failure to Prevent Tracheostomy Tubing from Contacting the Floor
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to management of tracheostomy tubing. On multiple observations over two days, three residents with tracheostomies were seen with their tracheostomy tubing in contact with or resting on the floor while connected to their airway, and no staff were observed intervening at those times. One resident, admitted most recently on 1/6/2026 with an original admission date of 7/10/2020, was observed in the morning with tracheostomy tubing extending from the tracheostomy site and resting on the floor, and again the following day in an electric wheelchair with the tubing touching the floor. Another resident, admitted on 10/7/2025 with diagnoses including traumatic hemorrhage of the left cerebrum with loss of consciousness (sequela), encounter for attention to tracheostomy, and functional quadriplegia, was observed with tracheostomy tubing touching the floor while connected to the airway. A third resident, admitted on 12/23/2025 with diagnoses including traumatic subdural and subarachnoid hemorrhages with loss of consciousness (sequela) and encounter for attention to tracheostomy, was observed during routine care with tracheostomy tubing in contact with the floor. During interviews, the Infection Preventionist (RN6) acknowledged that tracheostomy tubing should not come into contact with the floor due to contamination risk, noting that the floor was considered dirty and that residents were already immunocompromised. An LPN reported that they conduct rounds three times per shift and check tracheostomy residents, including whether tubing is on the floor, and further stated that if something touches the floor, the expectation is to replace it with something clean. The Assistant Director of Nursing stated that staff are not supposed to have anything on the floor but was unable to explain how tracheostomy tubing was consistently maintained off the floor. These observations and statements demonstrated a failure to implement proper infection control measures to prevent contamination of tracheostomy equipment.
Failure to Preserve Resident Dignity During Room Entry, Foley Care, and Medication Administration
Penalty
Summary
The facility failed to ensure residents were provided a dignified existence for 6 of 7 residents observed for dignity. Resident #126 and Resident #18 stated that staff did not knock, introduce themselves, or ask permission before entering their rooms. During observations, a GNA and a Unit Manager entered the residents’ rooms after a single knock without announcing themselves or asking permission to enter, and both staff members acknowledged that they should have introduced themselves and requested permission before entering. The facility also failed to maintain dignity during care and medication administration. Resident #126’s urinary Foley bag was repeatedly observed lying flat on the floor, full of urine, and without a privacy bag; later, an LPN attached the bag to a hook under the resident’s motorized wheelchair for an outside appointment, still without a privacy covering. In addition, during medication passes for Residents #162, #114, #229, and #183, an LPN and an RN administered multiple medications but did not inform the residents of the medications being given. Both nurses acknowledged that residents should have been told what medications were being administered.
Improper Storage of Opened Food Items in Walk-In Freezer
Penalty
Summary
The facility failed to store food in a manner that maintains professional standards of food service safety. During an initial tour of the kitchen on 09/15/25 at 8:44 AM, the surveyor and Certified Dietary Manager observed opened and unlabeled items in the walk-in freezer, including one box of pizza dough, one box of tortilla chips, one box of hamburger patties, and one box of French toast. During an interview on 09/16/25 at 8:58 AM, the CDM confirmed the facility's food storage policy is to securely close packages once opened and to label the package with an open date.
Infection Control and PPE Failures
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not consistently use appropriate PPE and did not follow transmission-based precaution practices. Resident #288 was on contact and droplet precautions, with signage on the door indicating the need for PPE, yet a GNA entered the room wearing only a surgical mask and without a gown, gloves, or N95 mask. The GNA stated she believed PPE was only needed when providing direct care. The Infection Preventionist stated staff were expected to don full PPE before entering the room, and the DON later stated N95 masks were kept on a locked medication cart and staff were expected to request them before entering the room. The facility also failed to maintain infection control during resident care. Resident #126’s urinary Foley bag was observed lying flat on the floor and full of urine on multiple occasions, without a privacy bag. RN #9 stated the bag would be hung under the bed, but later observations showed it remained on the floor. The DON later stated the resident said the bag drained better on the floor and then advised the resident that this was a concern and would notify the physician to assess placement. In a separate observation, Resident #126 had evidence-based practice precautions posted on the door, but when the resident needed help cleaning mucus from the face, a GNA entered without PPE and cleaned the resident while wearing only one glove. The GNA stated she did not need PPE because she was just cleaning the resident. The facility further failed to follow infection control practices with shared equipment and in the laundry area. RN #32 used the same shared blood pressure cuff on Resident #183 and then Resident #150 without sanitizing the cuff or equipment between residents. In the laundry room, Housekeeper #27 was observed folding linens and gowns with the bottoms touching the floor. The Housekeeping Assistant Manager agreed linen should not touch the floor and intervened by having the housekeeper use the folding table. Resident #14, who had chronic respiratory failure with hypoxia and end stage renal disease, was also observed with a nebulizer machine on the floor next to the bed during initial rounds.
Missed Quarterly Care Plan Meetings and Delayed Care Plan Revisions
Penalty
Summary
The facility failed to hold quarterly care plan meetings with the interdisciplinary team and failed to timely review and revise care plans for multiple residents. The deficiency was identified for 5 of 11 residents reviewed for care planning during the annual survey, including Residents #140, #120, #201, #232, and #285. Care plan meetings were described as meetings with the attending physician, the resident’s responsible RN, a nursing assistant, food and nutrition services, the resident, and the resident’s representative if applicable, and were required to occur quarterly so the care plan could be continually adjusted to resident needs. Resident #140 denied having any recent care plan meetings, and the record showed no care plan meeting between 07/03/24 and 03/22/25, with the last two meetings occurring on 07/02/24 and 03/23/25. Resident #120 had no care plan meeting since 03/06/25, and the Social Work Director confirmed a meeting was missed and stated the resident should have had one in June and another in September. Resident #201 had a care plan meeting on 06/18/24 and no other meetings until 03/20/25, with no meetings found from 06/19/24 through 03/19/25 or from 03/21/25 through the interview date; the Social Work Director confirmed missed meetings and stated the resident should have had meetings in September 2024, December 2024, June 2025, and September 2025. Resident #232’s POA reported no quarterly care plan meetings, and the record showed meetings on 06/11/24, 04/03/25, and 05/29/25, with the DON acknowledging concern that quarterly meetings had not been received. Resident #285 had multiple falls on 1/30/25, 2/17/25, 3/17/25, 6/7/25, and 7/31/25, but the fall risk evaluation dated 2/17/25 still classified the resident as low risk, and there was no evidence the care plan was updated after the 3/17/25 fall. The DON stated care plans were updated by the Unit Managers and himself and that interventions were expected to be updated after each fall incident, and later provided a revised fall care plan for the resident.
Delayed Call Bell Response
Penalty
Summary
The facility failed to ensure a call bell was answered in a timely manner for one resident who was fully dependent on staff for all needs. The resident stated that staff response to call bells was very delayed and requested that the door be left open halfway so the resident could call out for help after waiting long periods of time when the call bell went unanswered. The resident also reported needing to speak with the nurse because he or she did not feel well, and the surveyor observed a large amount of mucus dripping from the resident's nose down the face and onto the chin. The surveyor observed the resident press the call bell at 8:08 AM, while the door was halfway open. Three staff members walked past the resident's door, including the Unit Manager as identified by the resident, but no one answered the call bell. A GNA entered the room at 8:39 AM, stated she had been with another resident, cleaned the resident's face, nose, and chin, and then left after the resident asked for the nurse. An RN entered at 8:42 AM, and the resident told the nurse he or she did not feel well. The RN stated she would obtain vitals and conduct an assessment. The surveyor identified a 31-minute call bell response time, and the RN stated she saw the call bell light on but was administering medications and assumed the resident's needs had been addressed because she saw the Unit Manager in the hallway.
Failure to Provide and Document Showers
Penalty
Summary
The facility failed to ensure showers were provided for one resident who had requested them, affecting Resident #126 during the recertification survey. During an interview, the resident stated that showers had not been received despite requests. The resident’s family member also stated that showers had not been offered and noted that this had been discussed in a care plan meeting the prior week. A review of the resident’s care plan showed a care plan for refusal of showers, but the resident’s physician orders did not include an active shower order. The DON stated that residents are normally scheduled for two showers per week unless contraindicated and that a physician order is placed with the days and shift showers are to be provided. However, the ADL task form for the prior 30 days did not show that the resident refused baths/showers, and the DON confirmed there was no documentation of refusal. The DON later stated that the resident expressed wanting showers and that the resident then had an order for showers.
Failure to Document Discussion of Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were discussed with residents and/or responsible representatives for Resident #2, who was admitted and later readmitted to the facility with diagnoses including anoxic brain damage and end stage renal disease. A review of the clinical record found a MOLST form dated with verbal consent by the resident’s responsible representative for CPR in the event of cardiac and/or pulmonary arrest, but the record did not show the presence of an Advance Directive or documentation that the Advance Directive was discussed with the resident and/or responsible representative. Social Services assessments dated in the record also showed that information was not provided to the resident and/or responsible representative on Advance Directive. During interview, the Social Services Director stated that Advance Directives are discussed upon admission/readmission and at care conferences and educational material is offered, and then confirmed the surveyor’s findings after reviewing the resident’s record.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of resident transfers and discharges for 2 residents reviewed for hospitalization during the recertification survey. Resident #88 experienced a medical emergency and was transferred to a local hospital, and Resident #232 was also transferred to a local hospital. During the survey, the Nursing Home Administrator was asked to provide the Ombudsman notification for transfers and discharges, and later provided an email from the Social Service Director to the Ombudsman dated after the surveyor’s request, with attachments labeled as discharge transfer reports from January 2025 to the present. The Nursing Home Administrator acknowledged that the notification was emailed only after the surveyor requested it, and the Social Service Director stated that he had not provided notification of transfers and discharges to the Ombudsman since March 2024.
Inaccurate MDS Coding for Hospice and Ostomy Status
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents. For one resident, the clinical record showed a physician order dated 03/21/2025 to admit the resident to Hospice of the Chesapeake with a hospice diagnosis, and a Significant Change MDS completed on 03/31/2025 coded hospice care as Yes in Section O. However, a subsequent quarterly MDS assessment dated [DATE] coded hospice care as No in Section O. During interview, the MDS Coordinator confirmed this was an oversight and stated the hospice coding should have been marked as Yes. For another resident, an MDS assessment dated [DATE] recorded an ostomy in Section H for bladder and bowel, and the assessment was signed off as completed on 09/04/25. A continued review of the medical record showed no ostomy documented anywhere in the resident’s chart. During interview, the MDS Manager confirmed the resident did not have an ostomy and that the item had been inaccurately coded. A later record review showed the MDS assessment had been corrected and no longer identified the resident as having an ostomy.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide residents and/or their responsible representatives with summaries of their Baseline Care Plans. The deficiency was identified for 2 of 46 residents reviewed during the annual/recertification survey. A Baseline Care Plan is required to be completed within 48 hours of admission and to include initial goals based on admission orders, physician orders, dietary orders, therapy services, and social services, along with a summary and current medication list provided to the resident and/or responsible representative. Resident #3 was admitted in June 2025 with diagnoses including Chronic Respiratory Failure and Anoxic Brain and was ventilator dependent. Review of the clinical record on 09/18/25 found no evidence that the resident's Baseline Care Plan was discussed with the resident and/or responsible representative or that a copy was given. Resident #14 was admitted in August 2025 and was his own responsible party. Review of the clinical record on 09/18/2025 also found no evidence that Resident #14's Baseline Care Plan was discussed with him/her or that a copy was given. On 09/19/2025, the Director of Social Services stated that Baseline Care Plans are developed within 48 hours of admission and reviewed the records, confirming the surveyor's findings that there was no record showing this was done.
Missing Care Plan for Schizoaffective Disorder
Penalty
Summary
Resident #6 had a diagnosis of schizoaffective disorder, but a review of the resident’s care plan on 09/22/2025 at 1:10 PM showed that no care plan had been developed for that diagnosis. During the survey, the surveyor and the DON reviewed Resident #6’s care plan with revisions at approximately 1:30 PM, and the DON confirmed that the resident did not have a care plan for schizoaffective disorder. The report states that the facility failed to ensure resident care plans were developed, and this was identified for 1 of 1 residents reviewed for care plans during the recertification survey.
Resident with no decision-making capacity signed facility authorization forms
Penalty
Summary
The facility failed to ensure services met professional standards of practice when staff had a resident sign facility forms despite a physician certification stating the resident was unable to understand and sign admission documents, unable to understand the nature, extent, or probable consequences of proposed treatment, unable to make a rational evaluation of the burdens, risks, and benefits of treatment, and unable to effectively communicate a decision. The certification form was dated 06/05/23 and signed by two physicians. During the survey, the resident’s record was reviewed and the surveyor requested the bed hold notice related to the resident’s transfer to a local hospital after a medical emergency. The facility provided a Maryland Bed Hold Policy, Temporary Bed Hold Authorization, and Authorization to Record. Both forms were signed by the resident on 04/15/25, with the admission coordinator signing as the facility representative shortly afterward. The Temporary Bed Hold Authorization indicated the resident did not wish to authorize the facility to retain the bed at that time, and the Authorization to Record allowed the facility to take photographs or other audio-visual images for social media or marketing materials. During interviews, the NHA acknowledged the concern, and the admission coordinator stated she had the resident sign the forms to close them out even though she understood the resident did not have the capacity to understand and sign the forms.
Failure to Provide Daily Oral Care to a Dependent Resident
Penalty
Summary
The facility failed to provide ADL care to a dependent resident, specifically oral hygiene. Resident #20 was documented in the MDS as dependent for oral hygiene. During an observation on 09/16/2025, the resident’s teeth were seen with food particles present. A later observation on 09/22/2025 again showed pieces of food stuck to the resident’s teeth, and at another observation that same day, food particles were still present on the resident’s teeth. During interview, the resident’s representative stated that he/she did not believe the facility was adequately brushing the resident’s teeth. The assigned GNA stated that oral care is normally completed after breakfast and confirmed that oral care had not been provided on the last shift worked with the resident because the resident was asleep for most of the day. The GNA also stated that oral care is expected at least once daily. The Unit Manager stated that it was his expectation for residents to have their teeth brushed daily and confirmed that oral care is still expected even if a resident is asleep for extended periods. The Administrator stated that it was his expectation that residents have their teeth brushed at least twice a day.
Failure to Provide Ordered Pressure Ulcer Treatment
Penalty
Summary
The facility failed to ensure that Resident #126 received the ordered treatment for a pressure ulcer. The resident stated that the pressure ulcer had worsened to a stage 4. The care plan documented impaired skin integrity related to decreased functional mobility with pressure injuries to the sacrum, left ischium, right ischium, right heel, right plantar foot, left pinky finger, and right upper back/flank, and also noted risk for peristomal MASD related to colostomy exudate. During observation and interviews, the resident stated that the nurse did not have Dakins to cleanse the sacral pressure ulcer. An LPN confirmed that Dakins was not used because it was not available and said she used a squirt bottle labeled Skin Integrity Wound Cleanser instead. The MAR ordered cleansing the medial sacrum with NSS, applying Santyl, then covering the wound with 1/4 strength Dakin's moist dressing, gauze, and bordered gauze for wound treatment.
Respiratory Equipment Not Labeled and Oxygen Storage Procedures Not Followed
Penalty
Summary
Safe and appropriate respiratory care was not provided when the facility failed to date and label respiratory therapy equipment and failed to ensure oxygen storage procedures were followed for 2 residents reviewed for respiratory care. During initial rounds, Resident #14 was observed using oxygen via nasal cannula tubing, and the tubing was not labeled with when it was put into use or when it should be replaced. The Nurse Staff Educator later observed and confirmed this finding. Review of the resident’s record showed diagnoses including Chronic Respiratory Failure with Hypoxia and End Stage Renal Disease, and a physician order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath; the record did not contain an order to change the oxygen tubing. The facility policy stated that oxygen tubing and masks/cannulas are to be changed weekly and as needed if soiled or contaminated.
Failure to Complete Annual GNA Performance Reviews
Penalty
Summary
The facility failed to complete annual Performance Reviews for Geriatric Nursing Assistants at least every 12 months, as required to identify in-service education needed to address GNA competencies. During review of five GNA files, the surveyor found that GNA #5, hired in 2022, had a Performance Review due on 04/06/25, but the most recent review on record was dated 04/05/24. The record showed the annual review was not completed by the due date and remained incomplete at the time of the surveyor's review on 09/23/25. In interview, the DON stated that Performance Reviews for GNAs are conducted annually and as needed, and confirmed the surveyor's findings after reviewing the record. The DON later stated that GNA #5 was at work and provided a Performance Review completed on 09/24/25 after the surveyor's intervention.
Unattended Medications Left on Medication Cart
Penalty
Summary
The facility failed to ensure medications were stored properly when RN #32 administered medications to Resident #229 and left 1 medication cup of lacosamide 10 MG/ML oral solution, 1 medication cup of valproate acid 250 mg/5 ml solution, and 1 medication cup of levETIRAcetam oral solution 100 MG/ML on top of an unattended medication cart. During the observation, the RN entered the resident’s room carrying a cup of water and a medication cup of crushed medications in applesauce, then left the additional medication cups unattended on the cart. When interviewed, the RN acknowledged the medications should not have been left unattended and stated the facility policy is to keep all medications inside the medication cart when unattended. The DON later stated he had been notified of the observation of unattended medications.
Call Bells Not Within Reach of Residents
Penalty
Summary
A deficiency was cited for failure to ensure residents had access to call bells in their rooms. During an observation of Resident #140 on 09/16/25 at 11:14 AM, the resident was lying in bed and the call bell cord was curled into a circle and lying on the floor behind the head of the bed, out of reach. A repeat observation on 09/17/25 at 12:33 PM showed the resident sitting in a reclining chair with the call bell still wrapped in a circle on the floor behind the head of the bed. During an interview and observation with the DON on 09/17/25 at 12:50 PM, the DON agreed the call bell was not in reach of Resident #140. Resident #120 was also observed without accessible call bell access. On 09/17/25 at 9:32 AM, the resident was lying in bed and the call bell was lying on the floor behind the head of the bed. A repeat observation on 09/17/25 at 1:29 PM showed the resident sitting in a wheelchair beside the bed, while the call bell was on the opposite side of the bed near the wall and out of reach. During an interview and observation with Unit Manager #17 on 09/17/25 at 1:31 PM, she agreed the call bell was not within reach and should be accessible for the resident. The DON later stated on 09/19/25 at 6:52 AM that any time a resident is left in a room, staff should provide the resident with the call bell. The facility policy reviewed on 09/23/25 stated that a call light should be available at each resident's bedside, toilet, and bathing facility and within reach of the resident.
Leaking Corroded Pipe in Administrative Hallway
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in one administrative hallway observed during the annual survey. During the initial tour, surveyors observed two large bins covered with black plastic bags placed in the hallway between the DON's office and the Conference Room, with water dripping from the ceiling into the bins. The bags had visible holes, allowing water to collect at the bottom of the bins. Yellow caution tape was tied from a wet floor cone to the handrail, blocking access to that section of the hallway, and an orange and white cone was also present. The ceiling tiles above the bins appeared loose and mismatched, and one tile had a large brown stain. The same setup remained in place later that day and again on subsequent observations, with water continuing to drip from the ceiling into the bins. Interviews with the Administrator and Maintenance Director showed the pipe above the ceiling was corroded and leaking. The Administrator stated the leak had not been that bad until recently and that a contractor had already looked at the pipe. The Maintenance Director stated the pipe had aged out, maintenance had insulated it, but the leak continued. Maintenance logs and vendor correspondence showed the facility had identified the leaking pipe and was monitoring it, including stained ceiling tile replacement and requests for insulation materials, but no documentation was provided showing the corroded pipe itself had been repaired or replaced. The vendor confirmed prior visits and stated a proposal for the work was still pending at the time of the survey.
Failure to Complete Required Annual GNA Inservice Training
Penalty
Summary
The facility failed to provide continuing education training of no less than 12 hours per year for Geriatric Nursing Assistants (GNAs). During record review of five GNA files for the period January 1, 2024 to January 1, 2025, GNA #5, hired in 2022, and GNA #22, hired in 2015, were found not to have completed the required 12 hours of annual inservice training. Staff Development Nurse #23 stated that the facility provides at least 12 hours of inservice training annually through Relias and said she would check the records to see whether the employees completed the training. The DON later provided the inservice records for both GNAs, which showed that neither employee completed 12 hours of inservice training for the reviewed period. The DON confirmed the findings and stated that the computer system did not generate a training schedule for GNA #5, so that employee was unaware of the need to complete the training, and that inservice training had been scheduled for GNA #22 but was not completed.
Inaccurate Medication Documentation and MAR Errors
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with accepted professional standards for two residents. One resident was admitted with chronic respiratory failure and an anoxic brain injury and was ventilator dependent. The clinical record showed an NPO order, with nutrition and medications given through a G-tube, yet the physician order for atorvastatin was written as an oral tablet to be given by mouth at bedtime. The MAR showed nurses signed the medication as administered by mouth from the date it was ordered through 09/17/25, and the Unit Manager confirmed the resident was NPO and did not receive anything by mouth. A second resident had a complaint history of multiple falls during the stay. A progress note documented a fall in which the resident reported pain when the nurse touched the lower extremity, and PRN Tylenol was administered at that time. However, review of the June MAR showed the PRN Tylenol was not signed as given. The DON stated that during fall incidents nurses are expected to assess residents and administer ordered pain medication, and acknowledged the finding.
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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 Hyattsville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Hsc Pediatric Skilled Nursing Facility | 0.7 mi | ★★★★★ | 0 | 0 |
| Ascension Living Carroll Manor | 1.1 mi | ★★★★★ | 4 | 1 |
| Sacred Heart Home Inc | 1.2 mi | ★★★★★ | 6 | 0 |
| White Oak Rehabilitation And Nursing Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Jeanne Jugan Residence | 1.6 mi | ★★★★★ | 0 | 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.