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 The Village At Rockville during CMS and state inspections, most recent first.
Meal service did not maintain resident dignity when two residents were seated at dining tables while others around them were already eating. One resident waited about 2 minutes for a tray while nearby residents ate, and another resident remained unserved long enough for a tablemate to finish the entire meal before receiving lunch. A GNA said trays were delivered by meal ticket order, and the Administrator and DON acknowledged the concern.
Peeling paint and damaged contact paper were observed in multiple resident rooms, and the Maintenance Director stated he was not aware of the damage. Surveyors also tested sink hot water in several resident bathrooms and found temperatures above the safe range, with the boiler room set point at 124.8 degrees F. The Maintenance Director said the water was set high because it would cool before reaching the resident.
Food items were found stored past discard dates or without required labels in the kitchen refrigerator, deep freezer, and a 3rd floor pantry freezer. Surveyors observed expired and undated items such as cut vegetables, peppers, naan bread, chicken, meatballs, croissants, mashed potatoes, roast turkey, and waffles, while the Dining Director stated night shift staff were responsible for checking and discarding expired items but that items were sometimes missed. The pantry also had no temperature log documented at the time of observation, and posted rules required guest food to be labeled with name, room number, and date.
The facility failed to thoroughly investigate two abuse allegations involving injuries of unknown origin by not consistently conducting and documenting resident interviews and assessments. In both cases, initial incident reports listed actions such as initiating investigations, notifying physicians and families, and performing limited clinical assessments, but did not include resident interviews or broader assessments as protective steps. Investigation files contained multiple staff interviews but lacked documented interviews with other residents or clear assessment data tied to the incidents. The NHA acknowledged that interviewing both staff and residents is best practice and believed social services had completed resident interviews, yet could not produce documentation. The DON reported that non-interviewable residents were not interviewed and that monitoring occurred through observation and family contact, but was unable to provide complete assessment records related to the incidents.
A resident with HTN had orders for Amlodipine and Metoprolol with parameters to hold doses if SBP was below 110 and, for Metoprolol, if HR was below 60. Despite this, Metoprolol was administered when the resident’s SBP was 101, and multiple BP readings below the ordered parameter were documented without evidence that the physician was notified or that medications were held as ordered. Separately, maintenance hot water logs showed the same temperature values carried across all resident rooms using lines and arrows instead of recording actual temperatures for each room, and the Maintenance Director acknowledged the logs were not completed accurately.
A facility investigation into an alleged abuse/neglect incident found that a GNA provided care in a rushed and disruptive manner that did not meet acceptable standards of quality. A PDA and a family member reported that the GNA moved quickly, slammed and rapidly opened/closed cabinet doors in a resident’s room, and left a dirty blanket on the bed. The resident also reported that the staff member moved too quickly while providing care. Although abuse was not substantiated, these observations showed that the resident did not receive compassionate, quality care consistent with their preferences and goals.
A resident who had been receiving hospice services was disenrolled due to extended prognosis, but the facility completed the significant change MDS late. The MDS was signed 20 days after hospice disenrollment, and the DON confirmed during interview that the assessment was completed late.
A resident with category 4 blindness in both eyes did not have a care plan addressing the vision impairment. A complaint alleged the facility failed to provide accommodations, and record review confirmed there were no interventions in the care plan for blindness. The DON reviewed the care plan with the surveyor and confirmed the omission.
Pressure ulcer treatment orders were not continued or documented for two residents with Stage II wounds. One resident’s left buttock wound care order ended before being renewed, and treatment was not documented for two days; another resident’s xeroform wound care order was not renewed for several days, and the treatment was not documented in the TAR during that gap. A RN, LPN, nurse manager, and DON confirmed the orders should have been renewed and continued.
A resident with severe cognitive impairment and extensive transfer assistance needs sustained a deep laceration to the left leg during a bed-to-wheelchair transfer. The resident became dizzy while being stood and pivoted, and a GNA noticed the cut after the resident was seated in the wheelchair. The injury required ER treatment and sutures.
A resident receiving PEG tube feeding for dysphagia was observed asleep in bed with the HOB elevated while Glucerna 1.5 was infusing from an electronic pump. The enteral feeding bottle was not labeled with the date and time the feeding began, and the DON stated staff were expected to label the bottle when the feeding started.
Staff failed to follow infection control practices for multiple residents. An aide provided high-contact care to a resident on EBP without gloves and a gown, and an LPN used the same rolling BP machine on several residents without cleaning it between uses. The DON confirmed the BP equipment should be cleaned between residents.
A resident's MOLST form instructed to attempt CPR, but due to a miscommunication, staff did not initiate CPR when the resident was found unresponsive. The RN relied on a shift report form indicating a DNR status, which was incorrect. The RN supervisor also failed to initiate CPR after verifying the correct code status in the resident's chart. The attending provider later advised against CPR due to the resident's condition.
The facility failed to provide mandatory communication training for direct care staff, including GNAs, LPNs, and an RN. A review of training records for eight randomly selected staff members revealed no documentation of completed communication training. This deficiency was identified during an extended survey following an Immediate Jeopardy situation. The Nursing Home Administrator was informed, but no further evidence was provided.
The facility failed to report allegations of abuse within the required two-hour timeframe for multiple incidents. In one case, a resident alleged being compromised at night, but the report was delayed by over 24 hours. Another incident involved a resident claiming a staff member put their head in a toilet, with a similar reporting delay. Additionally, a resident requiring assistance was refused help by a GNA, and the incident was not reported until the following day. The facility did not initially identify these situations as potential abuse, contributing to the deficiency.
The facility failed to obtain informed consent for bed rail use for two residents. Observations revealed that both residents had bed rails in use, but their medical records lacked consent documentation. The DON stated that consent was part of the assessment process, but no evidence of consent was found. The NHA confirmed the absence of consent for both residents.
The facility failed to ensure pharmacists' recommendations on medication irregularities were communicated to physicians for three residents. Reports were not documented in medical records, and there was no evidence that physicians reviewed or acted on the recommendations, indicating a breakdown in communication and documentation processes.
A resident's call bell went unanswered for over 42 minutes on multiple occasions, despite staff expectations to respond within 8 minutes. Interviews with a GNA and LPN revealed the facility lacked a formal call bell policy, and the DON and NHA acknowledged the deficiency.
A resident who required assistance with transfers was denied help by a GNA after lunch, despite expressing discomfort and a desire to return to their room. The GNA refused to assist and dismissed the resident's requests, leading the resident to attempt to wheel themselves back to their room. Other staff eventually assisted the resident, and the incident was reported the next day. The GNA's actions were confirmed, resulting in her termination.
A facility failed to thoroughly investigate an abuse allegation involving a resident. A family member reported the alleged abuse to a supervisor, but the investigation lacked interviews with the family member, the resident, and the supervisor. The DON acknowledged the missing interviews during a discussion.
A facility failed to notify a primary care provider about a lab result for a resident with a urinary tract infection. A urine specimen was spilled in transit, and although a nurse was informed, there was no documentation of communication with the provider. The nurse's responsibility includes reviewing lab results, notifying the provider, and documenting the communication, which was not done in this case.
The facility failed to maintain a safe environment, with a broken lock on a housekeeping closet and unrepaired drywall in resident rooms. A housekeeping closet was found unlocked, and a hole in a bathroom wall was stuffed with toilet paper. The Maintenance Director was unaware of these issues, and no work orders were found for the damaged drywall.
The facility failed to include a resident's care plan in the transfer documentation during hospitalization. Interviews with LPNs revealed that while a transfer checklist was used, it did not include the care plan. The DON confirmed that care plans should be sent with residents, but this was not being done, resulting in a deficiency.
The facility failed to provide written transfer notices to two residents and their representatives during hospitalizations. For one resident, no written notice was found for two hospitalizations, and verbal notifications were inconsistently documented. For another resident, despite documentation of a hospital transfer due to respiratory distress, there was no evidence of a written notice being provided. The NHA and DON confirmed these deficiencies.
The facility failed to properly orient and document the transfer of two residents to the hospital. One resident's medical records lacked evidence of preparation for hospitalizations, while another resident was transferred for respiratory distress without documentation of being informed about the transfer. The DON confirmed these deficiencies.
The facility failed to provide written notification of its bed-hold policy to residents and their representatives upon transfer to a hospital. For two residents, there was no documentation of written notice, only verbal communication was noted. The facility was unable to produce evidence of written notifications, indicating a systemic issue in compliance with notification requirements.
The facility failed to develop comprehensive care plans for two residents. One resident's care plan lacked measurable goals and non-pharmaceutical interventions for managing psychosis, despite receiving psychotropic medications. Another resident's care plan did not indicate the presence of a hearing aid, even though it was noted in the MDS assessment. The DON confirmed these deficiencies.
A private duty aide, not licensed to feed residents, was observed feeding a resident who required assistance in the dining room. Despite the presence of other staff, no intervention occurred. The aide was hired for another resident and fed the resident multiple times without proper authorization.
A facility failed to provide clear guidelines for administering as-needed medications for constipation to a resident. The resident's MAR included three medications for constipation, with no instructions on which to administer first. Two orders were for the same medication, leading to potential confusion. The issue was acknowledged by the DON.
A facility failed to adequately monitor a resident's behavior and side effects related to psychotropic medication use. The resident, with moderate cognitive impairment and multiple medical diagnoses, was prescribed Duloxetine, Quetiapine, and Lorazepam. Despite orders to monitor behavior, the facility did not document specific behaviors or non-pharmacological approaches, nor did they monitor the resident for behaviors related to the prescribed antipsychotic.
The facility failed to store food items properly, leading to a risk of cross-contamination. A surveyor found a sausage without a label or date in the walk-in freezer, which was removed by the Dining Services Supervisor. Additionally, in the second-floor kitchen, a surveyor observed uncovered and unlabeled salsa and sour cream with a scoop inside. A dining server identified and removed these items after being shown by the surveyor. The Dining Director acknowledged the improper storage.
The facility failed to maintain accurate medical records by not voiding outdated MOLST forms when new ones were created, resulting in multiple active forms with conflicting orders for three residents. This issue was identified during a survey, revealing discrepancies between the electronic medical records and hard charts.
A facility failed to maintain proper infection control practices when a resident's Foley catheter bag was observed lying flat on the floor. A nurse confirmed the observation and acknowledged that the catheter bag should not be in contact with the floor. The nurse adjusted the bed to prevent the catheter from touching the floor, suggesting the bed had been lowered, causing the issue.
The facility failed to educate two residents or their representatives on the risks and benefits of pneumonia vaccinations, as evidenced by the lack of documentation for informed consent. The Infection Preventionist nurse confirmed this deficiency.
Meal Service Did Not Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure residents were treated in a manner that maintained dignity during meal service in the 2 Virginia Memory Care dining room. On 02/27/2026, residents were observed seated together at dining tables while some residents had already received meal trays and were eating, but Resident #168 had not yet been served. Resident #168 was observed looking around at the other residents while they were eating and did not receive the meal tray until approximately two minutes later. In another observation, Resident #57 was seated at the same table as Resident #87 and had not yet received a meal tray while Resident #87 was being assisted with lunch. Resident #57 remained without a meal tray for approximately 11 minutes after the observation began, and during that time Resident #87 completed the entire meal before Resident #57 was served. GNA #10 confirmed that trays were served based on meal tickets and delivered in the order tickets were received, with residents seated at tables randomly and assisted based on when they received their trays. She also stated that residents sometimes attempt to take food from another resident's tray and that staff try to ensure residents seated together receive trays around the same time. The Administrator and DON were informed of the concern and acknowledged it.
Peeling Room Surfaces and Excessive Hot Water Temperatures
Penalty
Summary
The facility failed to ensure that resident rooms were in good repair in 3 of 32 rooms observed. During a tour on 02/25/26, the Surveyor observed large areas of peeling paint behind the beds in rooms #3145 and #3147, and peeling contact paper on top of the nightstand in another resident room. During a later tour with the Maintenance Director on 03/02/26, the Surveyors and Maintenance Director again observed peeling paint on the walls behind the beds in rooms #3142, #3145, and #3147, along with peeling contact paper on the nightstand in the resident room. In an interview on 03/02/26, the Maintenance Director stated he was not aware of the damage and said he would get right on it. The facility also failed to ensure that residential hot water temperatures were safe in 5 of 5 resident rooms observed. During the continued tour, the Surveyors and Maintenance Director tested sink hot water in private bathrooms and found temperatures of 123 degrees F in room #2391, 124 degrees F in room #2390, 125 degrees F in one room, 123 degrees F in another room, and 124 degrees F in another room. The Maintenance Director stated that the residential hot water set point was 125 degrees F because the water temperature would decrease by a few degrees before reaching the resident. An observation in the boiler room showed the hot water temperature set point at 124.8 degrees F, and the Maintenance Director reported that he would reduce the hot water temperature.
Food Items Stored Past Discard Dates or Without Required Labels
Penalty
Summary
The facility failed to ensure food items were stored in accordance with professional standards for food service safety. During the kitchen facility task, a surveyor observed multiple items in the main kitchen refrigerator that were labeled for discard but had not been removed, including salad bar cut vegetables labeled discard by 02/23/2026 and cut green and red peppers wrapped in plastic wrap with no label or date. In the deep freezer, the surveyor observed additional items that were labeled for discard or were unlabeled and undated, including carrots labeled with a discard date of 02/15, opened naan bread with no label or date, red velvet iced sheet cake labeled discard 02/20, an unopened bag of meatballs with no label or date, opened chicken labeled good thru 02/23, an unopened bag of chicken with no label or date, croissants labeled discard 02/16/2026, and mashed potatoes labeled discard 02/22/2026. The Dining Director stated that night shift staff were responsible for reviewing items in the refrigerator and freezer each evening and discarding expired items during closing, and acknowledged that items were sometimes missed. During a dual observation with the Dining Director, the surveyor reviewed the expired and unlabeled items, including the meatballs, chicken, naan bread, and peppers, and the Dining Director acknowledged the concern and began discarding the identified items. On a later observation of the 3rd floor kitchen pantry on the Maryland Unit, the surveyor found no temperature recordings documented for that day and observed food items in the freezer that did not match the posted labeling and dating rules, including spicy chicken sandwich melts labeled only with a room number, a box of Stouffer's roast turkey dated 01/09/2026, and a box of Eggo waffles dated June 11, 2021.
Failure to Conduct and Document Resident Interviews and Assessments in Abuse Investigations
Penalty
Summary
Surveyors identified that the facility failed to thoroughly investigate two separate allegations of abuse related to injuries of unknown origin for two residents. For the first incident involving Resident #74, the initial incident report listed actions such as initiating an investigation and notifying the family, physician, medical director, and ombudsman, but did not include resident interviews or resident assessments as immediate protective steps. Review of the facility’s abuse investigation file showed eight staff interviews but no resident interviews or assessments. The follow-up investigation report also confirmed that only staff were interviewed. During interviews, the Nursing Home Administrator (NHA) acknowledged that including both staff and resident interviews is best practice and stated she believed the social worker had completed resident interviews. The DON reported that they do not interview residents who are considered non-interviewable, instead looking for signs or symptoms of abuse and contacting families, and indicated that any screening would be documented through skin assessments. However, the DON could only produce a limited number of skin assessments for some non-interviewable residents and these were not clearly tied to the abuse investigation. For the second incident involving Resident #140, the initial incident report for an injury of unknown origin documented steps such as initiating an investigation, completing a head-to-toe assessment, medicating for pain, notifying the physician, responsible party, and medical director, ordering an x-ray, and updating the care plan, but again did not list resident interviews or broader resident assessments as part of the immediate protective actions. The abuse investigation file contained nine staff interviews but no documentation of resident interviews or assessments. The follow-up investigation report indicated that only staff and the involved resident were interviewed. The NHA confirmed the investigation file was complete, reiterated that she believed the social worker had conducted resident interviews, and produced an email stating that three residents on the same hallway had been interviewed, but no written interview documentation could be provided. The DON stated they do not interview non-interviewable residents, instead monitoring for signs or symptoms and contacting families, and was unable to provide any documentation of completed resident assessments related to this incident, demonstrating that resident interviews and assessments were not consistently conducted or documented as part of the abuse investigations.
Failure to Follow Antihypertensive Parameters and Accurately Document Hot Water Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services met professional standards of practice for a resident receiving antihypertensive medications. Review of the resident’s MAR showed orders for Amlodipine 10 mg at bedtime and Metoprolol Succinate ER 50 mg daily for HTN, with instructions to hold both medications if the systolic blood pressure (SBP) was less than 110, and to hold Metoprolol if the heart rate was less than 60. On one morning, RN #28 administered Metoprolol despite the resident’s SBP being 101, which was below the ordered hold parameter. Review of the resident’s blood pressure readings showed multiple SBP values below 110 on several dates, including 103/57, 101/58, 102/57, 94/51, and 98/56. The medical record did not contain documentation that the physician was notified when the resident’s SBP was less than 110 or that the medication was held as ordered. A second deficiency was identified related to maintenance documentation of hot water temperatures. Review of the facility’s hot water logs showed that on multiple dates, a single temperature (ranging from 119°F to 121°F) was recorded with a line and downward arrow drawn through each box for every resident room, instead of documenting the actual temperature for each room. During interview, the Maintenance Director acknowledged that the hot water logs were not completed accurately or completely, confirming that the recorded temperatures did not reflect individual room measurements as required.
Failure to Provide Compassionate, Quality Care During Personal Care Interactions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident received care that met acceptable standards of quality, in accordance with orders, preferences, and goals. During review of a facility-reported incident involving allegations of abuse and neglect by a GNA toward one resident, multiple interviews documented concerns about the manner in which care was delivered. A Patient Decision Aide who worked with the resident on two consecutive days reported observing the GNA slamming cabinet doors in the resident’s room, moving quickly while opening and closing doors, and leaving a dirty blanket on the resident’s bed. These observations were recorded as part of the facility’s internal investigation. A family member of the same resident reported observing the GNA rapidly opening and closing cabinet doors in the resident’s room and stated that the GNA did not appear compassionate while providing care. In a separate interview, the resident reported that the GNA “moves too quickly” when providing care. Although the facility’s investigation did not substantiate abuse, the collected interviews consistently described rushed, abrupt care, environmental disruption (slamming and rapidly opening/closing cabinet doors), and failure to maintain a clean bed surface, which together demonstrated that the resident did not receive care that met acceptable standards of quality.
Late Significant Change MDS After Hospice Disenrollment
Penalty
Summary
The facility failed to complete a significant change MDS assessment within 14 days of a resident’s disenrollment from hospice services. Resident #43 had been admitted to hospice services on 12/23/2023, and a hospice physician certification of terminal illness documented hospice coverage for the benefit period beginning that date. A physician progress note later documented that the resident was disenrolled from hospice services due to extended prognosis, effective 1/23/2026, marking the end of the hospice benefit period. Review of Resident #43’s significant change MDS showed a reference date of 2/5/2026, and the assessment was completed and signed on 2/11/2026. This was 20 days after the resident’s disenrollment from hospice services and 5 days late. The DON confirmed during interview that the resident had been disenrolled from hospice and that the significant change MDS assessment was completed late.
Missing Care Plan for Resident With Blindness
Penalty
Summary
Failure to ensure a care plan was developed for Resident #166 was identified during the recertification and complaint survey. A review of complaint #2607648 reported that the facility failed to provide accommodations for the resident, and during a phone interview the complainant stated that Resident #166 was blind and that the facility did not have interventions in place to accommodate the resident's needs. Record review showed that Resident #166 had diagnoses of blindness in the right and left eye, category 4. Review of the resident's care plan showed that there was no care plan for blindness. During interview, the DON reviewed the resident's care plan with the surveyor and confirmed that the resident did not have a care plan for blindness, stating that the facility's expectation is that a resident with a vision impairment such as blindness has a care plan with interventions addressing the resident's needs.
Pressure ulcer treatment orders were not continued or documented for two residents
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not followed for two residents with Stage II pressure ulcers. For Resident #7, the record showed an order for left buttock wound care with normal saline, xeroform, and bordered gauze every dayshift for 14 days, but the order ended on 2/06/2026 and was not renewed until 2/09/2026. There was no documentation that the wound treatment was completed on 2/07/2026 or 2/08/2026. A Skin: Pressure Ulcer Assessment form completed on 2/05/2026 also listed xeroform as the treatment, but the treatment was not documented as completed during the gap in orders. For Resident #122, the TAR showed an order for cleansing the left buttock wound with normal saline, pat dry, apply xeroform, and cover with optiform once daily for three weeks, with the order ending on 2/18/2025 and not renewed until 2/28/2025. There was no documentation that the wound treatment was completed from 2/19/2025 through 2/27/2025. A Skin: Pressure Ulcer Assessment form dated 2/19/2025 identified the left buttock wound as a Stage II pressure ulcer and listed xeroform as the treatment, but that treatment was not found in the TAR during the period reviewed.
Injury During Transfer
Penalty
Summary
The facility failed to keep a resident free from injury during a transfer from the bed to the wheelchair. Resident #10 had a BIMS score of 07, indicating severe cognitive impairment, and required substantial to maximal assistance with transfers. The resident was also care planned for fall risk related to weakness, poor safety awareness, attempted self-transfers, and confusion. During the transfer, the resident reported becoming dizzy as the GNA stood them up and began pivoting them toward the wheelchair. While the resident was being seated in the wheelchair, the GNA observed a cut on the resident’s left leg. Medical record review confirmed the resident sustained a 6 cm by 5 cm laceration with a depth of 2 cm during the transfer, requiring transport to the ER for acute care. Subsequent documentation noted sutures were placed to treat the laceration, and staff interviews confirmed the injury occurred during the transfer process.
Unlabeled Enteral Feeding Bottle
Penalty
Summary
The facility failed to ensure that a resident's enteral feeding was labeled. Resident #34 was observed in bed asleep with the head of the bed raised to 45 degrees while an enteral feeding was infusing from an electronic feeding pump through the resident's PEG tube. During the observation, the enteral feeding bottle of Glucerna 1.5 was seen without a date and time indicating when the feeding began infusing, and a photo was taken of the unlabeled bottle by the surveyor. Record review showed that Resident #34 had an order for enteral feeding for dysphagia: Glucerna 1.5 cal via PEG tube using a pump at 50 ml/hr for 20 hours, starting at 2:00 PM, with 50 ml water flushes every hour while running. During interview, the DON stated that staff were expected to label the enteral feeding bottle with the date and time when the enteral feeding began infusing.
Failure to Follow Infection Control Practices
Penalty
Summary
The facility failed to ensure staff practiced infection control for 4 of 6 residents observed during the recertification survey. For Resident #138, the surveyor observed a sign on the room door for Enhanced Barrier Precautions (EBP), but GNA/PDA #30 was cleaning the resident’s face with a white cloth without wearing gloves and a gown during high-contact care. During interview, the GNA/PDA stated she was familiar with EBP because she washed her hands before and after care, and after reviewing the posted sign she stated she should have worn gloves and a gown. The surveyor also observed LPN #21 using a rolling blood pressure machine on Resident #3, then returning the machine to the hallway beside the medication cart without cleaning it before using it on Resident #65 and later Resident #131. The machine was not cleaned between residents on each occasion. LPN #21 confirmed the blood pressure machine was supposed to be cleaned after use and before taking it to a new room, and she acknowledged she did not clean it between residents. The DON stated the blood pressure cuffs should be cleaned between residents.
Failure to Initiate CPR Due to Miscommunication of Code Status
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) to an unresponsive resident whose Maryland Orders for Life Sustaining Treatment (MOLST) instructed to attempt CPR in the event of cardiac and/or pulmonary arrest. The incident involved a resident who was found unresponsive by a geriatric nurse aide (GNA) and subsequently assessed by a registered nurse (RN), who noted the resident had cold clammy skin, no rise and fall of the chest wall, and dilated pupils. Despite these observations, the RN did not initiate CPR, as the resident's MOLST form instructed. The failure to initiate CPR was attributed to a miscommunication regarding the resident's code status. The RN relied on a change of shift report form that incorrectly indicated the resident had a Do Not Resuscitate (DNR) order. This misinformation was compounded when the RN supervisor also failed to initiate CPR after checking the resident's physical chart, which correctly indicated the need to attempt CPR. The attending provider was contacted and advised against initiating CPR due to the resident's condition at that time.
Removal Plan
- The staffing agency was notified of the occurrence, and staff #8 was placed on the Do Not Return list for the facility.
- A document review was conducted on all units to ensure code status information was only available on the MOLST form in the residents' physical charts.
- Nursing staff were re-educated on MOLST and the CPR process by the RN unit managers.
- Policy on MOLST and CPR and education were activated in the facility's training software program for nursing staff review and acknowledgment.
- The 3 Unit Managers (Care Coaches) also provided in-person training to all nursing staff.
- The Medical Director provided education to all attending physicians (including Resident #137's attending provider).
- The facility audited and reviewed all residents' MOLST forms and orders.
Lack of Mandatory Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff received mandatory communication training, as evidenced by a review of training records for eight staff members, including Geriatric Nursing Assistants, Licensed Practical Nurses, and a Registered Nurse. During the extended survey portion of the recertification survey, it was discovered that none of the eight randomly selected staff members had documentation of completed communication training. This deficiency was identified following an Immediate Jeopardy situation during the standard survey, prompting a more in-depth review of staff training records. The Nursing Home Administrator was informed of the lack of evidence for mandatory communication training, but no further evidence was provided to address this deficiency.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to report allegations of abuse within the required two-hour timeframe for four facility-reported incidents. In one case, a responsible representative informed the facility of an allegation involving female residents being compromised at night, but the report to the Office of Healthcare Quality was delayed by over 24 hours. Another incident involved a resident alleging that a staff member put their head in a toilet, but the report was not made until the following morning. Similar delays were noted in two other incidents, where reports were made several hours after the allegations were initially reported to staff. Additionally, the facility did not identify and report potential abuse involving a resident who required assistance with transfers. The resident requested help from a geriatric nursing assistant (GNA) to return to bed after lunch, but the GNA refused, stating she would assist after dinner. The resident, experiencing discomfort, attempted to return to their room independently until another staff member intervened. The incident was not reported to the state survey agency until the following day, and the Director of Nursing was not informed until the report was sent. The facility's investigation revealed that the Care Coach did not follow up with the resident on the evening of the incident, and the Director of Nursing confirmed that the incident was not initially identified as abuse. The lack of immediate reporting and failure to recognize the situation as potential abuse contributed to the deficiency, as the facility did not adhere to the required protocols for timely reporting and addressing allegations of abuse.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to obtain informed consent prior to the initiation of bed rails for two residents. This deficiency was identified during a survey where Resident #120 was observed with bed rails in use, but a review of their medical record did not reveal a consent form for the bed rail use. The Director of Nursing (DON) explained that residents were assessed prior to the initiation of bed rails and that the consent could be found on the assessment form. However, upon review, the surveyor found no documentation of consent for Resident #120's bed rail use, and the Nursing Home Administrator (NHA) confirmed the absence of consent. Similarly, Resident #23 was observed with bed rails, and a review of their medical record also failed to reveal a consent form for the bed rail use. The DON reiterated the facility's process of assessment and consent documentation, but the surveyor again found no evidence of consent. The NHA confirmed that there was no consent for Resident #23's bed rail use. These findings indicate a failure by the facility to ensure that informed consent was obtained and documented prior to the use of bed rails for these residents.
Failure to Communicate Pharmacist Recommendations to Physicians
Penalty
Summary
The facility failed to ensure that pharmacists' recommendations regarding medication irregularities were communicated to the residents' physicians. This deficiency was identified during a survey for three residents who were reviewed for unnecessary medications. For Resident #51, the Director of Nursing (DON) was unable to provide the pharmacy report from November 2023, which contained potential irregularities and recommendations. The process described by the DON involved the pharmacist emailing the report to clinical management staff, who would then print and deliver it to the physician for review and signature. However, there was no documentation to confirm that the physician received or acted upon the pharmacist's recommendations. Similarly, for Resident #111, the DON could not provide the pharmacy review from October 2023, nor could she confirm whether any irregularities were addressed by the resident's physician. The same process was described, where the pharmacist's report was supposed to be reviewed and signed by the physician, but again, there was no documentation to verify that this occurred. The lack of documentation indicated a failure in the communication process between the pharmacist and the physician regarding medication irregularities. For Resident #117, the pharmacist's reports identified irregularities on three occasions, with recommendations for actions such as discontinuing duplicate medications and conducting specific tests. Although the reports were eventually provided, they were not part of the resident's medical record, and there was no documentation in the medical record to indicate that the attending physician reviewed or responded to the pharmacist's recommendations. This lack of documentation and communication highlights a systemic issue in ensuring that pharmacists' recommendations are properly addressed and documented in the residents' medical records.
Delayed Call Bell Response in LTC Facility
Penalty
Summary
The facility failed to respond timely to residents' call bells, as evidenced by a complaint involving a resident whose call bell went unanswered for 42 minutes or longer on multiple occasions. The complaint was reviewed during a recertification survey, revealing that the resident experienced delays on specific dates, with some instances occurring twice in a single day. Interviews with staff members, including a Geriatric Nursing Assistant (GNA) and a Licensed Practical Nurse (LPN), highlighted that the expectation was to answer call bells within 8 minutes, as communicated during staff meetings and orientation. However, the actual response times significantly exceeded this expectation. Further investigation revealed that the facility lacked a formal call bell policy. The Director of Nursing (DON) confirmed the absence of such a policy during an interview. The Nursing Home Administrator (NHA) and DON acknowledged the deficiency in call bell response times, confirming the delays and recognizing it as a deficiency. The report does not mention any corrective actions or follow-up measures taken to address the issue.
Failure to Protect Resident from Abuse by GNA
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident involving a geriatric nursing assistant (GNA) and a resident who required assistance with transfers. The resident, who needed help moving from bed to wheelchair and back, requested assistance from GNA #15 to return to their room after lunch. The GNA refused to assist the resident, stating that she would help when she was ready, despite the resident expressing discomfort and a desire to return to their room. The GNA further dismissed the resident's request by telling them to be quiet and that they would be taken back after dinner. The resident attempted to wheel themselves back to their room, and other staff members noticed and assisted the resident. The incident was reported to the Assistant Director of Nursing the following morning. An interview with GNA #15 confirmed that she refused the resident's request for assistance and also prevented visitors from helping the resident. The Director of Nursing later substantiated the abuse, leading to the termination of the GNA.
Failure to Investigate Abuse Allegation Thoroughly
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident. On January 9, 2023, a family member reported to a supervisor that the resident alleged abuse and retaliation by staff. The facility's investigation included interviews with staff members assigned to the resident during the time of the alleged abuse and some residents. However, the investigation lacked documentation of an interview with the family member who reported the allegation, the resident involved, and the supervisor who initially received the report. During a discussion on October 10, 2024, with the Director of Nurses (DON), it was revealed that these critical interviews were missing from the investigation. The DON acknowledged the concerns and expressed surprise that the interviews were not included. This oversight indicates a failure to conduct a comprehensive investigation into the abuse allegation, as essential interviews were not documented.
Failure to Notify Primary Care Provider of Lab Result
Penalty
Summary
The facility failed to notify a primary care provider of a lab result for a resident reviewed for urinary tract infections. On 9/20/24, a urine culture and sensitivity test for the resident was compromised as the specimen was spilled in transit. This incident was communicated to a Registered Nurse, identified as Staff #14. However, there was no documentation in the resident's medical record indicating that this information was communicated to the primary care provider. An interview with the Registered Nurse Care Coach/Unit Manager confirmed that it is the nurse's responsibility to review lab results and notify the primary care provider, as well as document the communication and the provider's response. The Director of Nursing was made aware of the failure to notify the provider of the lab result.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe and well-repaired environment, as evidenced by several maintenance issues that were not addressed in a timely manner. On the Potomac Unit's 2nd floor, a housekeeping closet was found unlocked with a broken keypad lock, allowing access to cleaning supplies and hand sanitizers. This was confirmed by a registered nurse and the Director of Nursing, who acknowledged the deficiency. Additionally, a hole in the wall of a hallway bathroom was observed, which was stuffed with toilet paper. The Maintenance Director was unaware of the issue until it was pointed out during the survey. In two resident rooms, the drywall behind the beds was gouged, exposing the underlying surface. Despite multiple observations, the damage remained unaddressed. The Maintenance Director stated that work orders for non-emergent issues were processed through the front desk and tracked via a computer system. However, he was not aware of any work orders for the damaged drywall in these rooms and noted that repairs could not be completed while the rooms were occupied. Documentation showed previous repairs in other rooms, but no current work orders for the affected rooms were found.
Failure to Include Care Plan in Resident Transfer Documentation
Penalty
Summary
The facility failed to include the resident care plan with the required documentation during a transfer, as evidenced by the case of Resident #45, who was hospitalized on two occasions. During interviews with several Licensed Practical Nurses (LPNs), it was revealed that the nurses used a transfer checklist to ensure required documents were sent with the resident upon transfer. However, the review of the transfer form checklist did not indicate the inclusion of a care plan. Multiple LPNs confirmed that they would not send the resident's care plan upon transfer. The Director of Nursing (DON) acknowledged that the care plan should be sent with residents upon transfer, but this was not being practiced, leading to the deficiency.
Failure to Provide Written Transfer Notices
Penalty
Summary
The facility failed to provide written notification of transfer to residents and their representatives, as required. This deficiency was identified for two residents who were hospitalized. For the first resident, the medical record review revealed that the resident was hospitalized on two occasions, but there was no evidence of a written transfer form being provided to the resident or their representative for these hospitalizations. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) confirmed that the facility typically did not provide written notices to residents and only verbally informed the representatives, which was not consistently documented. For the second resident, the medical record indicated a transfer to a hospital due to respiratory distress. Although there was documentation of the transfer and verbal notification to the resident's representative, there was no evidence that a written notice was provided to the resident or their representative. The NHA and DON acknowledged the deficiency, noting that while a transfer notice form was supposed to be completed and given to the resident and/or representative, it was not consistently done, and the documentation was not found in the medical records.
Failure to Prepare and Document Resident Transfers
Penalty
Summary
The facility failed to properly orient, prepare, and document the transfer of two residents to the hospital. For one resident, the medical record review revealed hospitalizations on two separate dates, but there was no documentation indicating that the resident was prepared and oriented for these transfers. The Director of Nursing (DON) confirmed that the facility used progress notes and a transfer form to document transfers, but the review of these documents did not show evidence of preparation and orientation for the resident. For another resident, the medical record indicated a transfer to an acute care facility due to respiratory distress. Although the SBAR communication documented the resident's condition and the physician's order for transfer, there was no evidence that the resident was informed about the reason for the transfer or that the resident's understanding was documented. The DON acknowledged these concerns when they were brought to her attention.
Failure to Provide Written Bed-Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of its bed-hold policy to residents and their representatives upon transfer to an acute care facility. This deficiency was identified during a review of medical records for two residents who were hospitalized. For one resident, the electronic medical record indicated a transfer to a hospital due to respiratory distress, but there was no documentation that the resident or their representative received written notice of the bed-hold policy at the time of transfer or within 24 hours in the case of an emergency. Interviews with the Nursing Home Administrator (NHA) and the Director of Nurses (DON) revealed that while verbal notifications were given, written notices were not consistently provided or documented in the residents' records. Similarly, for another resident who was hospitalized on two occasions, the facility failed to provide evidence of a written bed-hold policy notification. The NHA admitted that the policy notifications were not always given to residents and were not consistently uploaded into the electronic medical record, relying instead on verbal communication. Despite requests from the surveyor, the facility was unable to produce documentation of the written notifications for the resident's hospitalizations, highlighting a systemic issue in ensuring compliance with notification requirements.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility staff failed to develop and implement comprehensive, resident-centered care plans for two residents during a recertification survey. For one resident, who was moderately cognitively impaired and had diagnoses including anxiety disorder and depression, the care plan did not include measurable goals and non-pharmaceutical interventions for managing psychosis. The resident was receiving psychotropic medications, including Quetiapine for hallucinations and psychosis, and Ativan for agitation, restlessness, and anxiety. Despite these treatments, the care plan only addressed potential complications from psychotropic drugs and lacked a comprehensive approach to the resident's condition. Another resident, who had a hearing aid, was found to have a care plan that failed to indicate the presence of the hearing aid. The Minimum Data Set (MDS) assessment had noted the hearing aid, but the care plan was not updated to reflect this information after the most recent care plan meeting. The Director of Nursing confirmed the deficiency, acknowledging that the care plan should have included the hearing aid information.
Unlicensed Feeding Assistance by Private Duty Aide
Penalty
Summary
The facility failed to ensure that only licensed staff fed residents, as observed during a recertification survey. On the 2nd floor Potomac Unit dining room, an unidentified female without a name badge was seen feeding a resident in a wheelchair, identified as Resident #39, who required feeding assistance. This individual was later identified as a private duty aide (PDA #2) hired for another resident, Resident #11. PDA #2 fed Resident #39 multiple times, leaving and returning to the table, while other facility staff were present in the dining area and hallways. Interviews conducted with a Geriatric Nursing Assistant (GNA #3) and the unit manager, a Registered Nurse (RN #1), confirmed that PDA #2 was not licensed and should not have fed Resident #39. The Director of Nursing (DON) explained that PDA #2 had been working with Resident #11 for over a year and was asked by Resident #11 to assist Resident #39. Despite the presence of other GNA staff who observed the incident, no intervention occurred. The DON acknowledged the deficiency and stated that PDA #2 should have informed the nurse or assigned GNA about Resident #39's need for assistance.
Inadequate Parameters for As-Needed Constipation Medications
Penalty
Summary
The facility failed to maintain a resident's drug regimen free from unnecessary medications by not providing adequate parameters for administering as-needed medications for constipation. During a review of the medical record for a resident, it was found that the September Medication Administration Record (MAR) included three medications prescribed as needed for constipation, with no clear guidelines on which medication to administer first. Two of these orders were for the same medication, Polyethylene Glycol Powder. The orders included lactulose oral solution to be taken every 12 hours as needed, Miralax Powder to be taken once a day as needed for no bowel movement, and Polyethylene Glycol Powder to be taken every 24 hours as needed. The lack of clear instructions in the physician orders led to confusion about which medication should be administered first for constipation relief. This issue was discussed with the Director of Nurses, who acknowledged the concern.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident's medication regimen was free from unnecessary psychotropic medication by not adequately monitoring the resident for behavior, side effects, or adverse consequences related to psychotropic medication use. This deficiency was identified for one resident who was admitted to the facility following an acute hospitalization. The resident had moderate cognitive impairment, medically complex conditions, and multiple medical diagnoses, including dementia, anxiety disorder, and depression. The resident was prescribed an antipsychotic and an antidepressant, and received antipsychotics on a routine basis. The medical record review revealed that the resident was prescribed Duloxetine for depression, Quetiapine for hallucination and later for psychoses, and Lorazepam for restlessness, agitation, and anxiety. Despite orders to monitor the resident's behavior for agitation and mood decline, the facility failed to document specific behaviors or individualized, non-pharmacological approaches to care. Additionally, there was no documentation indicating that the resident was monitored for the specific behaviors for which the antipsychotic Seroquel had been prescribed. The Director of Nurses acknowledged these concerns during a discussion with surveyors.
Improper Food Storage Leading to Cross-Contamination Risk
Penalty
Summary
The facility failed to properly store food items to prevent cross-contamination, as observed during a survey. On one occasion, a surveyor found a sausage wrapped in plastic without a label or date in the walk-in freezer, which was subsequently removed by the Dining Services Supervisor. In another instance, a surveyor observed two metal containers in the second-floor kitchen of the Maryland unit. One container held red sauce, identified as salsa, without a cover or label, and the other contained an open bag of sour cream with a serving scoop inside. A dining server identified the items and removed them for disposal after being shown by the surveyor. The Dining Director acknowledged that the items should not have been left uncovered and unlabeled in the refrigerator.
Failure to Void Outdated MOLST Forms
Penalty
Summary
The facility staff failed to maintain complete and accurate medical records by not voiding outdated Maryland Orders for Life Sustaining Treatment (MOLST) forms when new ones were created for residents. This deficiency was identified during a review of medical records for three residents, where it was found that each resident had multiple active MOLST forms with conflicting orders. For instance, one resident had an active MOLST form in their electronic medical record (EMR) indicating 'No CPR, Option B,' while their hard chart contained a different active MOLST form with 'No CPR, Option A-2.' Similar discrepancies were found in the records of the other two residents. The issue was brought to light during a survey when the surveyor requested copies of the active MOLST forms. The Nursing Home Administrator (NHA) acknowledged the concern and indicated that the MOLST forms were intended to be kept only in the paper chart, not in the EMR. The failure to void previous MOLST forms when new ones were created led to the presence of multiple active forms with conflicting orders in the residents' medical records.
Infection Control Deficiency: Foley Catheter Bag on Floor
Penalty
Summary
The facility failed to use appropriate infection control practices for a resident with an indwelling Foley catheter. During an observation, the surveyor noted that the resident's Foley catheter bag was lying flat on the floor. This observation was confirmed by a nurse, who acknowledged that the catheter bag should not be in contact with the floor. The nurse then adjusted the bed to ensure the catheter was no longer touching the floor, indicating that the bed had likely been lowered to its lowest position, causing the catheter bag to rest on the floor.
Failure to Educate on Pneumonia Vaccination Risks and Benefits
Penalty
Summary
The facility failed to ensure that residents or their representatives were educated on the risks and benefits of pneumonia vaccinations. This deficiency was identified during a survey for two residents. For one resident, the immunization record indicated a refusal of consent for vaccines, but there was no documentation showing that the resident or their representative was informed about the health benefits and risks of receiving vaccinations. Similarly, another resident's representative refused a pneumococcal vaccination, yet there was no evidence of education provided regarding the risks and benefits of the vaccination. The Infection Preventionist nurse confirmed the lack of documentation for educational efforts in these cases.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,075 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Collingswood Rehabilitation And Healthcare Center | 1.2 mi | ★★★★★ | 18 | 0 |
| Sterling Care Rockville Nursing | 1.5 mi | ★★★★★ | 8 | 0 |
| Shady Grove Nursing And Rehabilitation Center | 1.7 mi | ★★★★★ | 4 | 0 |
| Potomac Valley Rehabilitation And Healthcare | 1.9 mi | ★★★★★ | 3 | 0 |
| Ingleside At King Farm | 2.4 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.