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 Residences At Vantage Point during CMS and state inspections, most recent first.
Missing Documentation of Pharmacist MRR Irregularities: Monthly pharmacist MRRs for several residents noted irregularities and recommendations, but the written reports and physician responses were not in the medical record and were instead kept in a binder or the DON’s office. For one resident on Metoprolol ER for HTN, the MAR showed daily administration without documentation of BP or pulse checks to confirm the medication was given within ordered hold parameters, and the pharmacist did not identify that monitoring irregularity.
Advance directive documentation was missing for multiple residents, and there was no evidence that the residents or their representatives were informed of the right to formulate an advance directive. Review of paper records and EMRs for three residents failed to show an advance directive or documentation of resident/representative discussion. A SW stated the SNF had previously relied on the CCRC wellness center for copies and had recently created an admissions checklist that included advance directives.
A resident had a significant weight loss after missing monthly weights for two months, with documented weight dropping from 320 lbs. to 281.8 lbs. The care plan required staff to alert the MD/RD of significant weight changes, but there was no documentation that the physician or another medical provider was notified. A later CRNP note stated appetite satisfactory and weight stable, with no indication the CRNP was aware of the weight loss.
Incomplete and Non-Resident-Centered Care Plans: Surveyors found that care plans were not comprehensive or measurable for multiple residents. One resident on oxygen had no respiratory care plan despite an order for supplemental O2 and observed use of a nasal cannula. Another resident after hip surgery lacked care plan interventions for immobility, positioning, ADLs, and seizure precautions, and an ADL intervention was inaccurate because the resident was non-ambulatory. A third resident with dementia, anxiety, agitation, and mood disorder had a behavior/psychotropic care plan that misclassified Depakote as an antipsychotic and did not address the resident’s symptoms with resident-centered interventions.
Failure to provide ordered oxygen and document respiratory care: A resident with diastolic HF and a hx of PE was observed on multiple occasions receiving O2 via NC from a concentrator set at 3 L/min, although the MD order was for 2 L/min PRN for SOB. Staff did not document the resident’s O2 sat, respiratory status, or response to the intervention, and the TAR was not signed off on several observed dates. The resident also had no care plan addressing respiratory/pulmonary problems or O2 use.
Failure to Address Significant Weight Gain: A resident had a 7.7% weight gain over 8 days, but the RD did not document the change or note follow-up in the chart. The MD also did not evaluate or address the significant weight gain, and progress notes reviewed did not mention it. The AD confirmed there was no documentation showing the MD addressed the weight gain.
A resident's drug regimen was not kept free from unnecessary drugs when staff failed to follow the physician's hold parameters for Metoprolol ER ordered for HTN. The MAR showed the medication was given daily, but there was no documentation that BP and pulse were checked before administration or that the dose was held when SBP was below 110 or pulse was below 60.
Incomplete MOLST and weight documentation in resident records. Multiple residents had more than one active MOLST in the chart, including older CPR and newer No CPR orders that were not voided, and one resident had an unsigned MOLST filed with active orders. A resident’s weight record was also inconsistent, with missing monthly weights, scribbled-out entries on paper logs, and weights not entered consistently into the EMR; staff could not explain the missing or changed documentation.
Respiratory equipment was not properly date labeled, cleaned, or stored for two residents. One resident’s nasal cannula tubing was observed without a date label, and the record did not include instructions for cleaning or replacing the oxygen equipment. Another resident’s CPAP mask was observed uncovered and later on the floor, while staff could not identify the manufacturer’s cleaning instructions and the record lacked specific directions for cleaning, drying, storage, and replacement of CPAP components.
The facility was found to have multiple deficiencies in food safety and equipment maintenance, including improper food storage, malfunctioning refrigeration units, and inadequate dishwashing sanitization. Staff lacked awareness of proper protocols, and management was not fully informed of these issues, indicating a lack of oversight.
A privacy breach occurred when an unattended monitor displayed resident images and medical record numbers in a hallway. A GNA acknowledged the issue, and the DON confirmed the concern, instructing the GNA to secure the monitor. The Executive Director was informed, and the issue was discussed during the exit conference.
The facility failed to timely report injuries of unknown origin for two residents. One resident sustained a hematoma after sliding from a wheelchair, and the incident was not reported until a hip fracture was later identified. Another resident's shoulder dislocation was reported nearly 23 hours after x-ray confirmation. The facility's reporting and investigation processes were found lacking, contributing to the deficiencies.
A resident sustained a hip fracture and a hematoma after falling from a wheelchair, but the facility failed to conduct a thorough investigation. The incident was reported as an injury of unknown origin, yet no comprehensive investigation file was maintained. The facility's documentation lacked a detailed root cause analysis, and options for an abuse investigation were not selected.
A facility failed to conduct quarterly care plan meetings for a resident, as required. The resident, admitted in June 2024, did not recall being invited to any meetings and expressed a desire to attend one. A review of the medical record showed no evidence of a care plan meeting after the initial one in June. The Health Center Social Worker confirmed the oversight, acknowledging that the resident should have had a meeting in September.
An LPN failed to follow infection control practices during medication administration, including not sanitizing hands after handling a dropped medication bottle and before administering medications to residents. Additionally, used syringes were improperly discarded in a sharps container.
Missing Documentation of Pharmacist Medication Regimen Review Irregularities
Penalty
Summary
The facility failed to develop and implement policies and procedures for medication regimen reviews by not ensuring that pharmacist-identified irregularities were documented in residents’ medical records, including the physician’s response and any rationale for action taken or not taken. Surveyors found that monthly pharmacist medication regimen review notes for multiple residents stated “see report” for irregularities and recommendations, but the corresponding written reports were not present in the medical records. Instead, the reports were located in a binder at the nurses’ station or in the DON’s office and had not been uploaded into the residents’ records. For one resident receiving Metoprolol ER for HTN with hold parameters for SBP less than 110 or pulse less than 60, the February and March 2026 MARs showed the medication was administered daily, but there was no documentation that BP or pulse had been obtained before administration to show the medication was given within the ordered parameters. Monthly pharmacist reviews for this resident were completed, but the medical record did not contain the written irregularity reports or any physician response, and the pharmacist did not identify the irregularity related to administration without evidence of adequate monitoring. For other residents reviewed for unnecessary medication, monthly pharmacist reviews documented irregularities and recommendations, but the corresponding reports and physician responses were not found in the medical record. The NHA acknowledged that the pharmacist reports were kept in the DON’s office and in a binder on the unit and had not yet been uploaded into resident records. The report identified this issue for multiple residents, including residents with repeated pharmacist reviews over several months, where the irregularities and provider responses were present in separate paper reports but absent from the medical record.
Advance Directive Documentation Missing for Multiple Residents
Penalty
Summary
The facility failed to reveal evidence that residents or their representatives were informed of the right to formulate an advance directive, and failed to ensure that a current copy of a resident's advance directive was in the medical record for 3 of 11 residents reviewed. For Resident #5, review of the paper record and EMR failed to reveal an advance directive or any documentation that the resident or representative had been informed of the right to formulate one or wished to do so. Resident #5 had resided in the SNF since March 2023. For Resident #12, review of the paper record and EMR failed to reveal an advance directive or documentation that the resident or representative had been informed of the right to formulate one or wished to do so. Resident #12 had resided in the SNF since December 2025. For Resident #4, review of the paper record and EMR likewise failed to reveal an advance directive or documentation that the resident or representative had been informed of the right to formulate one or wished to do so. Resident #4 had resided in the SNF since October 2025. During interview, Staff #9 stated that prior to January 2026 the SNF only admitted residents within the CCRC and could obtain a copy of a resident's advance directive from the wellness center, and that a marketing person addressed admissions for residents not from the CCRC. Staff #9 also stated a checklist for admissions including advance directives had recently been created. After being informed of the concerns, Staff #9 later provided advance directives for Residents #5 and #4 and stated one still had to be obtained for Resident #12, but no additional documentation was provided by the end of the survey.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician when Resident #13 was identified as having a significant weight loss. The resident’s weight was documented as 320 lbs. on 12/5/25, with no weights recorded for January or February 2026. When the resident was weighed on 3/4/26 and again on 3/5/26, the weight was 281.8 lbs., reflecting a loss of 38.2 lbs. or 11.94% over 3 months. A weight change note entered by the DON on 3/5/26 identified the significant weight loss and stated that the dietitian would address it and that the resident would be placed on weekly weights. The resident’s Nutrition Plan of Care, originally developed on 12/5/24 and revised on 3/5/26, included an intervention to weigh per orders and alert the MD/RD of any significant weight changes. Despite this, there was no indication in the record that the physician or another medical provider was notified when the significant weight loss was identified on 3/4/26 and 3/5/26. A monthly provider note written by a CRNP on 3/11/26 stated appetite satisfactory and weight stable, but there was no documentation showing the CRNP was aware of the weight loss. During interview, the MDS nurse stated that physician notification should be documented in the resident’s record.
Incomplete and Non-Resident-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable goals and interventions for multiple residents. Surveyors identified deficiencies related to respiratory care, unnecessary medications, positioning and mobility needs after hip surgery, seizure precautions, and behavioral/psychiatric care. The report states that care plans did not reflect the residents’ assessed needs, physician orders, or ongoing treatment requirements. For one resident, the surveyor observed the resident lying in bed wearing a nasal cannula connected to an oxygen concentrator. The medical record showed an order for oxygen at 2 L/min via nasal cannula as needed for shortness of breath, and the treatment record documented oxygen administration on some dates but not on the date of observation. The resident’s care plans did not address respiratory or pulmonary problems or the need for supplemental oxygen. Staff stated the resident was prescribed oxygen for diastolic heart failure and a history of pulmonary embolism. For another resident, the record showed admission after revision of a left hip hemiarthroplasty with orders for bed positioning, a left hip abductor brace, a left knee extension brace, an abductor pillow, and restrictions on wheelchair use. The resident’s MDS documented severe cognitive impairment, lower-extremity ROM limitation, dependence for all ADLs, and diagnoses including dislocation of the internal left hip prosthesis, presence of a left artificial hip joint, and seizure disorder. The care plans did not include comprehensive, measurable interventions for limited ROM, immobility, positioning needs, ADL dependence, or seizure disorder, and one ADL intervention listed ambulation despite the resident being non-ambulatory. For a third resident, the record documented dementia, anxiety, aggressive behavior, agitation, intermittent insomnia, intermittent depressive symptoms, and use of Depakote for mood disorder and agitation. The care plan incorrectly identified Depakote as an antipsychotic medication and did not include resident-centered interventions for the mood disorder or the behaviors for which the medication was prescribed. The behavior management care plan listed delusional behavior, wandering, and behaviors toward staff, but the goal was not measurable or resident centered, and the interventions did not identify underlying reasons for the behaviors or include nonpharmacological approaches directed at understanding, preventing, or relieving the resident’s distress.
Failure to Provide Ordered Oxygen and Document Respiratory Care
Penalty
Summary
Facility staff failed to ensure that Resident #18 received respiratory care and services consistent with professional standards of practice. On 3/9/26, the resident was observed lying in bed with a nasal cannula connected to an oxygen concentrator that was set at 3 L/min, although the physician’s order was for oxygen at 2 L/min via NC as needed for shortness of breath. The resident was observed again on 3/13/26 and 3/17/26 with the concentrator still set at 3 L/min. The resident’s medical record included the 2 L/min order on the TAR, but the facility had not developed a plan of care to address the resident’s respiratory/pulmonary problems or oxygen use. The TAR showed staff signed off oxygen administration on 3/6/26 and 3/10/26, but not on 3/9/26, 3/13/26, or 3/17/26 when the resident was observed receiving oxygen. No progress notes were found documenting the resident’s oxygen administration, assessment, oxygen saturation, respiratory symptoms, or response to the oxygen intervention. The CRNP stated the resident was prescribed oxygen for diastolic heart failure and a history of pulmonary embolism. An LPN stated the facility protocol was to use oxygen when saturation was below 90%, but she had not checked the resident’s saturation and had not documented the assessment or intervention.
Failure to Address Significant Weight Gain
Penalty
Summary
The facility failed to ensure that a physician addressed a significant weight gain for Resident #3. A review of the medical record showed the resident’s weight increased from 181 pounds on 2/24/26 to 195 pounds on 3/1/26, a 7.7% gain in 8 days. The record also showed that the dietician did not document the 7.7% weight gain in the medical record and no other follow-up was noted by the dietician. Continued review failed to show that the physician evaluated or addressed the significant weight gain when it was identified, and progress notes reviewed on 3/9/2026 did not mention the weight gain. During interview, the Administrator Director confirmed that no documentation was present to indicate the physician had addressed the resident’s weight gain.
Failure to Follow BP and Pulse Parameters for Metoprolol
Penalty
Summary
The facility failed to keep a resident's drug regimen free from unnecessary drugs by not following physician orders to monitor blood pressure and pulse before administering Metoprolol Succinate for hypertension. For Resident #6, a 1/31/26 order directed staff to give Metoprolol ER daily and hold the medication if systolic blood pressure was less than 110 or pulse was less than 60. Review of the February 2026 MAR showed the medication was administered every day, and review of the March 2026 MAR showed it was also administered daily from 3/1/26 through 3/12/26. In both months, there was no documentation on the MAR showing that blood pressure and pulse were checked before administration or that the medication was given within the ordered parameters. The concern was discussed with the RN/MDS Coordinator, who acknowledged it and offered no further comment.
Incomplete MOLST and weight documentation in resident records
Penalty
Summary
The facility failed to keep complete and accurate medical records for residents’ advance directives and weights. Review of records and staff interviews showed multiple MOLST forms in several residents’ charts that were not properly voided when new orders were created, and one resident had an unsigned MOLST kept with active orders. The report also identified missing and inconsistent weight documentation for another resident, with weights recorded on paper logs but not entered consistently into the EMR and no explanation documented for missed weights. For one resident, the paper chart contained a voided MOLST and an unvoided MOLST, while the EMR contained more than one unvoided MOLST, including an older order for Attempt CPR and a newer order for Option A-1, Intubate. For another resident, the paper record contained an active MOLST for No CPR, Option A-2, DNI, along with an unsigned, undated MOLST for No CPR, Option B, Palliative and Supportive Care; the EMR also contained two unvoided MOLSTs, including an older Attempt CPR order and a newer No CPR order. For a third resident, the paper record contained multiple copies of unvoided MOLSTs and one voided MOLST, and the EMR also contained more than one unvoided MOLST with differing selections. The report states that when updated MOLSTs were completed, older forms were not voided in accordance with the form instructions. Additional record review found two MOLST forms for another resident, both signed by the CRNP and both indicating No CPR Option B, with neither form voided; the EMR also contained a scanned MOLST indicating Attempt CPR. For a different resident, the paper chart contained a MOLST indicating No CPR Option A-2 DNI and another MOLST signed by the CRNP that had VOID written diagonally across it but no signature or date, and the scanned copy in the EMR did not include the VOID notation. For the weight documentation issue, one resident had a documented weight of 320 lbs. on one date, no weights recorded for January or February 2026, and a later weight of 281.8 lbs. Staff provided paper monthly weight sheets showing missing entries, scribbled-out weights, and weights that did not match the EMR. Staff interviews showed uncertainty about who obtained the weights, why documentation was missing, and when or why weight entries were changed.
Respiratory Equipment Not Properly Labeled, Cleaned, or Stored
Penalty
Summary
The facility failed to ensure respiratory care equipment was properly date labeled and cleaned and stored according to manufacturer instructions for two residents receiving respiratory therapy. Resident #18 was observed using oxygen via nasal cannula, and the tubing had a piece of white tape with a handwritten date on one observation, but on a later observation the nasal cannula tubing had no date label. The resident’s record included an order for oxygen at 2L/min via nasal cannula as needed for shortness of breath, but there was no information in the record about how or when staff were to clean or replace the oxygen equipment. Resident #13 was observed with a CPAP machine on the nightstand, with the humidification/water chamber in the machine and the CPAP tubing draped over the table. The face mask was observed hanging uncovered over the side of the table and later lying on the floor under the head of the bed. The resident was unable to identify how the facility cleans and maintains the CPAP equipment or where the manufacturer’s instructions were located. Staff #7 also could not identify where to find the manufacturer’s instructions for cleaning, drying, storage, or replacement of the CPAP components beyond the filter. Resident #13’s record included physician orders and TAR instructions for CPAP use at bedtime, changing distilled water daily, changing and inspecting the filter, and cleaning the CPAP and tubing weekly with soap and water. However, the record did not contain specific directions for cleaning and drying the machine or tubing, cleaning the water chamber and face mask, replacing those components, or storing the face mask when not in use. The facility policy stated that specific cleaning instructions are obtained from the manufacturer or supplier, but the manufacturer’s instructions were not found in the resident’s paper record.
Deficiencies in Food Safety and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a surveyor's inspection. The surveyor noted multiple instances of improper food storage, including unlabeled and undated food items, as well as expired products that were not discarded. The walk-in refrigerator and freezer contained various food items that were either improperly labeled or not labeled at all, with some items showing signs of spoilage. Additionally, the temperature gauges on the refrigeration units were not functioning correctly, leading to discrepancies in recorded temperatures and actual conditions inside the units. The dishwashing system was also found to be deficient, with the machine operating below the required temperatures for effective sanitization. The facility was using a chemical sanitizing mode due to a failed booster heater, but the chemical concentration was not consistently tested or recorded, and when tested, it was found to be below the required levels. The temperature logs for the dishwasher consistently showed that the minimum required temperatures were not met, and there was no documentation of corrective actions taken to address these issues. Furthermore, the facility's staff demonstrated a lack of awareness and understanding of proper food safety protocols. Interviews with dietary staff revealed that there was no consistent practice for monitoring food temperatures during preparation and serving. The facility's management, including the Administrator and Dining Services Director, were not fully aware of the ongoing issues with the kitchen equipment and food safety practices, indicating a lack of oversight and communication within the facility's operations.
Privacy Breach of Resident Information
Penalty
Summary
The facility failed to maintain the privacy of protected health information for 11 out of 21 residents during a recertification/complaint survey. Surveyors observed an unattended and unlocked monitor screen in the resident hallway displaying photo images and medical record numbers of 11 residents. This occurred on 12/11/24 at 3:13 PM. Geriatric Nursing Assistant (GNA) #12 was identified on the screen, and upon being informed by surveyors, acknowledged the issue and closed the screen. The Director of Nursing (DON) was also informed and confirmed the concern, instructing GNA #12 to lock the monitor screen. The Executive Director was made aware of the issue on 12/13/24, and the concern was reiterated during the facility's exit conference.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin to the Office of Health Care Quality, as evidenced by two incidents involving Resident #220. In the first incident, the resident was found on the floor after sliding out of a wheelchair, sustaining a hematoma to the forehead. Despite the severity of the injury, the facility did not report the incident to the Office of Health Care Quality until several weeks later, when a hip fracture was identified. The facility's Administrator acknowledged that they do not keep investigation files for every fall and only report incidents when injuries are involved, which led to the delay in reporting. In the second incident, the facility delayed reporting an acute anterior humeral head dislocation for another resident. The resident complained of left hand pain, and an x-ray confirmed the dislocation. However, the facility did not report the injury to the Office of Health Care Quality until nearly 23 hours after receiving the x-ray results. The delay in reporting was noted by the surveyor, who found that the facility's self-report was sent the day after the injury was identified. Both incidents highlight the facility's failure to adhere to timely reporting requirements for injuries of unknown origin. The lack of immediate reporting and investigation into these incidents raises concerns about the facility's processes for identifying and addressing potential abuse or neglect. The surveyor's review of the facility's documentation and interviews with the Administrator revealed gaps in the facility's reporting and investigation procedures, contributing to the deficiencies identified during the survey.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation for an injury of unknown origin involving a resident who sustained a hip fracture. The incident was initially reported as an injury of unknown source to the Office of Health Care Quality. The resident had a fall from their wheelchair, which was documented in a nursing progress note. The note indicated that the resident was found face down in front of the wheelchair with a hematoma on the left side of the forehead. Despite the severity of the injury, the facility did not maintain a comprehensive investigation file for this incident. During interviews, the facility's Administrator acknowledged that no separate investigation file was kept for the fall, and the incident was not reported to the Office of Health Care Quality as an injury of unknown origin. The risk meeting documentation provided was insufficient, lacking a detailed root cause analysis or evidence of how the interdisciplinary team reached their conclusions. The facility's incident report marked the event as an alleged fall, unattended, but did not select options for an abuse investigation or ruling out abuse, further indicating a lack of thorough investigation into the incident.
Failure to Hold Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to hold care plan meetings at least quarterly for a resident, as required. This deficiency was identified during a recertification/complaint survey. The resident, admitted in June 2024, reported not recalling being invited to any care plan meetings and expressed a desire to attend one. A review of the resident's medical record showed no evidence of a care plan meeting after the initial one in June. The Health Center Social Worker confirmed that residents should have quarterly care plan meetings and acknowledged missing the September meeting for this resident. Despite searching through various records, no documentation of a subsequent care plan meeting was found.
Infection Control Lapses During Medication Administration
Penalty
Summary
During a recertification/complaint survey, it was observed that the facility failed to adhere to proper infection control practices during medication administration. An LPN was seen dropping a medication bottle on the floor and subsequently placing it back in the medication cart without sanitizing it or their hands. The same LPN administered medications to a resident and left the room without sanitizing their hands, then proceeded to take another resident's blood pressure. Additionally, the LPN handled a water pitcher and administered medications to another resident without sanitizing their hands after setting up a new computer on the medication cart. Furthermore, two used syringes were found in the top part of a sharps container on the medication cart, accessible due to the lever not being pulled to discard them properly.
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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 Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lorien Health Systems - Columbia | 2.4 mi | ★★★★★ | 37 | 0 |
| The Lutheran Village At Miller's Grant | 3.3 mi | ★★★★★ | 0 | 0 |
| Ellicott City Healthcare Center | 4.9 mi | ★★★★★ | 51 | 0 |
| Lorien Nursing & Rehab Ctr - Elkridge | 5.4 mi | ★★★★★ | 20 | 0 |
| Encore At Turf Valley | 5.7 mi | ★★★★★ | 0 | 0 |
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