Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Ingleside At King Farm during CMS and state inspections, most recent first.
Unsanitary conditions were observed in the dish machine room during the annual survey. Steam was escaping from both ends of the high temperature conveyor dish machine and scattering throughout the room, and excessive black buildup was seen on the vent stacks, dropdown ceiling tile edges, and drywalls. Staff confirmed the dish machine room would be scheduled for deep cleaning and maintenance review.
Missed Required Attending Provider Visits: A resident on hospice care was not documented as being seen face-to-face by an attending provider at least every 60 days. The chart showed a 166-day gap between provider visits, and interviews confirmed the resident’s record lacked documentation for the period in question, despite the provider stating visits were alternated with a NP.
A resident receiving duloxetine and other medications had a pharmacist recommendation to document the need for the antidepressant and consider a GDR. The attending provider did not act on the recommendation for an extended period, even though additional MRRs were completed before it was addressed, and the DON confirmed the delay in review and response.
Essential kitchen equipment was not maintained in proper operating condition during the annual survey. Surveyors observed a nonfunctional hand sink by the food prep area with a posted notice that the faucet had not worked since earlier in the month, and staff confirmed a work order had been submitted. Surveyors also observed a Continental undercounter freezer turned off, and staff confirmed the unit was nonfunctional and had a work order submitted.
The facility failed to adhere to professional standards for food storage, as observed by a surveyor. Opened and unlabeled food items, uncovered containers, and expired products were found in various storage areas, including the produce refrigerator and meat/fish cooler. The Certified Food Services Manager confirmed these findings, which were contrary to the facility's policy requiring proper labeling and disposal of expired foods.
A resident's private duty aide improperly used a gait belt as a restraint to prevent the resident from getting up out of their wheelchair. This incident was identified by a nurse and confirmed through a facility investigation, which substantiated the improper use of physical restraints. The facility had policies requiring PDAs to follow its procedures, but the aide's actions were contrary to these guidelines.
A resident with cognitive impairment was found with a swollen leg and bruise, and the facility failed to report the injury within the required 2-hour timeframe and delayed submitting investigation results. The initial report was submitted 24 hours after discovery, and the investigation results were submitted 6 days later, both outside the required timeframes.
Facility staff failed to ensure a resident received routine dental care. A resident's medical record indicated an order for a dental evaluation due to a broken tooth, but there was no documentation of prior dental services. The NHA stated that the facility does not provide routine dental services, and residents are informed to arrange their own care, with the facility only arranging appointments when a concern is identified.
The facility failed to document a dental treatment plan for a resident and did not complete beneficiary notifications correctly for two residents. One resident's discharge lacked a Notice of Medicare Non-Coverage, and another's SNFABN was incomplete. The NHA and Director of Social Services acknowledged these deficiencies.
The facility staff failed to maintain a homelike environment, as evidenced by damaged drywall behind residents' beds in three rooms observed during a medication administration assessment. A surveyor noted marring on the walls, which was confirmed by an RN and an LPN. The LPN admitted not noticing the damage until it was pointed out, and the RN had been on vacation prior to the survey. The staff used an app to report maintenance issues, but the damage had not been reported before the surveyor's observation.
A facility failed to revise a resident's care plan to address communication needs, despite frequent refusal to wear hearing aids and updated recommendations from an audiologist. The resident, with dementia and hearing deficit, required visual cues for communication. The care plan did not reflect these needs or the resident's refusal to use hearing aids, as confirmed by the ADON.
The facility failed to maintain professional standards in monitoring resident weights, as two residents experienced significant weight loss without proper follow-up. A resident lost 10.17% of their weight, and another lost 6.99% within a month. The Registered Dietician identified the issues but faced delays in reweighing and lacked documentation for weekly reweigh orders. Additionally, there was no documentation of refusals or immediate reweighs to confirm weight accuracy.
A facility failed to ensure an LPN on the memory care unit completed necessary dementia training. The LPN's last documented training had expired, and the recent training lacked detailed dementia care content. The HR Director confirmed annual training assignments, but the completed training only mentioned cognitive impairment, not dementia.
The facility staff did not update the staffing sheets on two units after changes to the schedule. A GNA was documented as working but had called out, and two GNAs called in to work were not reflected on the sheets. The DON acknowledged that updates are supposed to be transcribed to the daily staffing sheet, which was not done.
A facility's pharmacy failed to administer a prescribed supplement with a dosage for a resident during a medication administration survey. The blister package containing Vitron C lacked a specified dose, although the MAR indicated it was to be given twice daily for anemia. An LPN acknowledged having called the pharmacy to verify the dose. A pharmacist confirmed that the pharmacy typically does not send medications without a dose and expressed willingness to add the strength of the supplement if needed.
Unsanitary Conditions in Dish Machine Room
Penalty
Summary
The facility failed to provide a sanitary environment for residents, staff, and the public during the initial kitchen tour of the annual survey. At 10:30 AM, the surveyor observed steam escaping from both ends of the high temperature conveyor dish machine and scattering throughout the dish machine room. The surveyor also observed excessive buildup of black substances on the surfaces and open seams of the two vent stacks, along with significant buildup of black substances along the edges of the dropdown ceiling tiles and the drywalls in the mechanical dish room.
Missed Required Attending Provider Visits
Penalty
Summary
Facility staff failed to ensure that Resident #5 was seen face-to-face by an attending provider at least every 60 days. A medical record review showed provider visit notes on 3/4/25, 3/5/25, 3/10/25, 3/12/25, 3/31/25, 4/1/25, 4/8/25, 4/11/25, 4/21/25, 4/28/25, and 6/18/25, but no documented attending provider visits from August 2025 until the next visit on 12/1/25, leaving a 166-day gap between visits. During interviews, the director of clinical operations stated residents must be seen by an attending provider at least every 60 days after admission, and the attending provider stated visits were alternated between him and a NP and sometimes recorded in the physical chart. A follow-up review of the resident’s physical chart still showed no evidence of provider visits during the August-to-December 2025 period, and the provider confirmed the chart lacked documentation for that time.
Delayed Review of Pharmacy Recommendation
Penalty
Summary
The facility failed to ensure that attending physicians reviewed and acted on pharmacist-identified irregularities in a timely manner for one resident who had been receiving multiple medications, including duloxetine for depression. Monthly medication review notes showed that on 8/8/25 the pharmacist recommended documenting the need for duloxetine 60 mg daily and considering a gradual dose reduction to 40 mg daily if appropriate. The resident had been in the facility since 2019 and remained on the antidepressant during the period reviewed. The attending provider did not sign the 8/8/25 pharmacy recommendation until 10/29/25, 82 days after it was made, and responded by reducing the antidepressant from 60 mg to 30 mg daily. The DON stated that pharmacy recommendations were usually faxed to the provider’s office and flagged in the resident’s hard chart, and confirmed that this recommendation had not been addressed for two months even though subsequent monthly medication reviews were completed on 9/17/25 and 10/9/25 before the 8/8/25 recommendation was acted on.
Nonfunctional kitchen equipment observed during survey
Penalty
Summary
The facility failed to maintain essential kitchen equipment in proper operating condition, as observed during the annual survey for 2 of 2 pieces of equipment reviewed. During an initial kitchen tour with staff, a sign was posted on a nonfunctional hand sink located by the food preparation area stating that the faucet had not been working since 3/18/2026. Staff confirmed that a work order had been submitted for the sink. Later in the tour, the surveyor observed a Continental undercounter freezer turned off, and staff confirmed that the unit was nonfunctional and that a work order had been submitted.
Failure to Maintain Professional Standards in Food Storage
Penalty
Summary
The facility failed to store food in accordance with professional standards of food service safety, as observed during a survey of the main kitchen. The surveyor noted several instances of opened and unlabeled food items, including bags of carrots, lettuce, spinach, and chicken nuggets, as well as various containers of sauces and condiments. Additionally, there were uncovered items such as a large tub of apple cider, a pan of greens, and a tub of chicken stock. Expired items were also found, including a container of ginger garlic paste and a jar of capers. These observations were made in the produce refrigerator, meat/fish cooler, main freezer, and dry goods storage area. The surveyor confirmed these findings with the Certified Food Services Manager (CFSM) #4, who acknowledged the presence of opened, unlabeled, and expired foods. The facility's Food and Supply Storage policy requires that unused portions and open packages be covered, labeled, and dated, and that expired foods be discarded by their respective dates. The CFSM provided evidence of an in-service conducted with kitchen personnel to review proper labeling and dating procedures, although this action is not part of the deficiency itself.
Improper Use of Gait Belt as Restraint by Private Duty Aide
Penalty
Summary
The facility failed to maintain an environment free of physical restraints, as evidenced by an incident involving a resident's private duty aide (PDA) improperly using a gait belt as a restraint. The incident was identified when a nurse observed the PDA using the gait belt to prevent the resident from getting up out of their wheelchair. This action was contrary to the intended use of a gait belt, which is meant to assist with mobility and not to restrict movement. The facility conducted an investigation and substantiated the improper use of physical restraints by the PDA. Interviews with staff confirmed that there were no other instances of physical restraint use. The PDA was contracted by the resident's family, and the facility had policies in place that required PDAs to adhere to the facility's procedures, including those related to nursing care. The incident was one of four facility-reported incidents reviewed during the survey.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin within the required 2-hour timeframe and did not submit the results of the investigation within 5 days to the Office of Health Care Quality. This deficiency was identified during a review of a facility reported incident involving a resident who was found with a swollen left leg and a bruise on the left shin during activities of daily living care. The Director of Nursing was informed of the incident shortly after it was discovered and initiated an investigation. The resident involved had a BIMS score of 2, indicating significant cognitive impairment, and was unable to provide information about the injury. The facility was unable to determine the cause or timing of the incident. The initial report to the Office of Health Care Quality was submitted approximately 24 hours after the incident was discovered, and the investigation results were submitted 6 days later, both outside the required reporting timeframes.
Failure to Provide Routine Dental Care
Penalty
Summary
Facility staff failed to ensure a resident received routine dental care, as evidenced by the case of a resident who was reviewed for dental services during the survey. The resident's medical record showed a progress note from November 2021 indicating an order for a dental evaluation due to a broken tooth. However, there was no documentation in the medical record to confirm that the resident received any dental services prior to the incident of the broken tooth. During an interview, the Nursing Home Administrator (NHA) stated that the facility does not provide routine dental services and that residents are informed to arrange their own dental care, with the facility only arranging appointments when a concern is identified.
Deficiencies in Medical Record Documentation and Beneficiary Notification
Penalty
Summary
The facility staff failed to ensure that a resident's medical record included all necessary documentation related to dental treatment. Specifically, for one resident, a progress note indicated an order for a dental evaluation due to a broken tooth. However, the documentation of the treatment plan following the dental visit was missing, even after the Power of Attorney was contacted. The Nursing Home Administrator (NHA) was unable to provide the required documentation when requested by the surveyor. Additionally, the facility did not correctly complete beneficiary notification documentation for two residents. One resident was discharged without receiving a Notice of Medicare Non-Coverage (NOMNC) due to a lack of notice about the discharge, and there was no documentation to support that the discharge was requested by the resident. For another resident, the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) was incomplete, as the resident did not select one of the required options regarding Medicare and payment. The Director of Social Services acknowledged the oversight.
Failure to Maintain a Homelike Environment Due to Wall Damage
Penalty
Summary
The facility staff failed to maintain a homelike environment, as evidenced by damaged drywall behind residents' beds in three of the six rooms observed during a medication administration assessment. Specifically, the surveyor noted marring on the walls behind the beds of three residents. During the observations, both a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) confirmed the surveyor's findings. The LPN acknowledged that the resident's bed might have caused the damage, despite having a stopper. However, the LPN admitted not noticing the damage until it was pointed out by the surveyor. Additionally, the RN had been on vacation for two weeks prior to the survey and had not reported the damage before that day. The staff used a computer-generated app named Worxhub Links to report maintenance issues, but the damage had not been reported prior to the surveyor's observation.
Failure to Revise Care Plan for Resident's Communication Needs
Penalty
Summary
The facility failed to ensure that a resident-centered care plan was revised to meet the needs of a resident, specifically in response to current interventions related to communication and sensory needs. The deficiency was identified for a resident with diagnoses including dementia, anxiety, hearing deficit, and major depressive disorder. The resident had physician orders to use bilateral hearing aids and required visual cues for effective communication. However, the resident frequently refused to wear the hearing aids, citing discomfort and excessive noise, and this refusal was documented multiple times over several months. Despite an audiology visit that adjusted the hearing aids to a comfortable volume and provided updated recommendations for communication, the care plan was not revised to reflect these changes or the resident's refusal to wear the hearing aids. The care plan, initially created in October 2023 and revised in January 2024, did not include the resident's refusal to wear hearing aids or the updated communication strategies recommended by the audiologist. This oversight was confirmed during an interview with the Assistant Director of Nursing, who acknowledged the resident's inconsistent use of hearing aids and the lack of updated documentation in the care plan.
Failure to Monitor Resident Weight Loss
Penalty
Summary
The facility failed to maintain professional standards of practice regarding the monitoring of resident weights, as evidenced by the cases of two residents. Resident #7 experienced a significant weight loss of 10.17% within approximately one month, dropping from 108.2 lbs to 97.2 lbs. The Registered Dietician (Staff #23) identified the weight loss and suspected a scale error, requesting a reweigh on 01/06/25, which was not conducted until 01/08/25. Despite recognizing the significant weight loss, there was no documentation of an order for weekly reweighs for four weeks, and Staff #23 did not report the delay in reweighing to her supervisor. Similarly, Resident #21 experienced a 6.99% weight loss within about a month, from 146.0 lbs to 135.8 lbs. The Registered Dietician noted the significant weight loss but faced difficulties in reweighing the resident and could not find documentation of a refusal to be reweighed. There was also no documentation of an order for weekly reweighs for four weeks. The Registered Nurse (Staff #5) indicated that significant weight differences should prompt immediate reweighing to confirm accuracy and that any refusal to be weighed should be documented, which was not evident in this case.
Deficiency in Dementia Training for LPN
Penalty
Summary
The facility staff failed to ensure that a Licensed Practical Nurse (LPN) working on the memory care unit had completed the necessary competency training to effectively care for residents with dementia. During the Medicare/Medicaid survey, it was found that the LPN's last documented dementia training had expired, and the training they completed did not provide detailed information on caring for residents with dementia. The Director of Human Resources confirmed that annual training assignments are given to staff, and a report is sent to supervisors to track completion. However, the training completed by the LPN only mentioned cognitive impairment without specific focus on dementia care, which is not equivalent to a diagnosis of dementia.
Failure to Update Staffing Sheets in LTC Facility
Penalty
Summary
The facility staff failed to update the staffing sheets on two units in the Long-Term Care Wing after changes were made to the staffing schedule. On the day of the survey, the surveyor reviewed the Daily Nursing Schedule log and found discrepancies in the staffing documentation. Specifically, on one unit, a Geriatric Nursing Assistant (GNA) was documented as working, but had called out, and this was not reflected on the staffing sheet. Additionally, two GNAs were called in to work that day, but their presence was not updated on the staffing sheets. The Director of Nursing acknowledged that sometimes staff call the scheduler directly when unable to work, and updates are supposed to be transcribed to the daily staffing sheet, which was not done in this instance.
Pharmacy Fails to Administer Prescribed Supplement Dosage
Penalty
Summary
The facility's pharmacy failed to administer a prescribed supplement with a dosage for Resident #19, who was observed during a medication administration survey. On February 14, 2025, at 9:41 AM, during the observation of Resident #19's medication administration, the surveyor noticed that the blister package containing Vitron C did not have a specified dose. The medication administration record (MAR) indicated that Vitron C 65-125 MG (Iron -Vitamin C) was to be administered by mouth twice a day for anemia. Licensed Practical Nurse #8, who was preparing the medications, acknowledged having previously called the pharmacy to verify the dose. On February 18, 2025, the surveyor interviewed Pharmacist #17, who confirmed that the pharmacy typically does not send medications or supplements without a dose. Later, Pharmacist #12 explained that it was not feasible to list all ingredients in a supplement and that the dose might be written on the MAR, but the medication only comes in one form. Pharmacist #12 also stated that the pharmacy would be willing to add the strength of the supplement or medication if needed.
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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 Rockville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shady Grove Nursing And Rehabilitation Center | 1 mi | ★★★★★ | 4 | 0 |
| Collingswood Rehabilitation And Healthcare Center | 1.6 mi | ★★★★★ | 18 | 0 |
| Sterling Care Rockville Nursing | 2 mi | ★★★★★ | 8 | 0 |
| The Village At Rockville | 2.4 mi | ★★★★★ | 25 | 0 |
| Wilson Health Care Center | 2.7 mi | ★★★★★ | 3 | 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.