Villa Rosa Nursing And Rehabilitation, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Mitchellville, Maryland.
- Location
- 3800 Lottsford Vista Road, Mitchellville, Maryland 20721
- CMS Provider Number
- 215350
- Inspections on file
- 16
- Latest survey
- January 14, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Villa Rosa Nursing And Rehabilitation, Llc during CMS and state inspections, most recent first.
Surveyors identified multiple failures to meet professional standards, including unsecured medication carts and visible resident health information left on unlocked computers, a physician-ordered CBC that was never completed, and inadequate behavior monitoring and documentation for several residents with psychiatric or dementia-related diagnoses who were receiving psychotropic medications. Staff acknowledged that behavior episodes documented on the TAR should be followed by detailed progress notes and, when indicated, SBAR assessments, but such documentation was missing despite repeated behavior entries and ongoing antipsychotic use. In addition, a resident was found wearing a Lidocaine transdermal patch without any physician order or MAR documentation, contrary to facility policy requiring valid orders and recorded application sites for all medications, including patches.
Surveyors identified dignity concerns involving two residents when staff failed to follow expected practices for privacy and communication. In one case, a GNA entered a resident’s closed room without knocking or introducing herself, contrary to the DON’s stated expectation that staff knock, wait for a response, and greet the resident upon entry. In another case, a resident reported feeling anxious, offended, and disrespected because a GNA primarily used hand gestures and pointing instead of verbal communication during care; this concern was echoed by the resident’s POA and documented in a psychiatric note, and the Administrator confirmed that the GNA had used non-verbal communication in this manner.
Surveyors identified a failure to maintain a sanitary and safe environment when large, unrepaired holes were found in the ceilings of the laundry drying area and clean linen folding room, exposing pipes, dust, and drywall near clean clothing and linens. The Maintenance Director reported long-standing building leaks, stated that the ceiling openings were created to access plumbing for repairs, and acknowledged that they remained open due to limited maintenance staffing and delayed full plumbing replacement related to budget and other priorities. The Administrator acknowledged the environmental concerns associated with the ongoing leaks and resulting ceiling damage.
A resident reported to an RN Unit Manager, with a social work staff member present, that a GNA failed to change the resident’s brief after a request for care, but this allegation was not relayed to leadership or reported to OHCQ within the required two-hour window; instead, the Administrator only became aware after receiving a family letter and then filed the report. In a separate issue, the NHA acknowledged that an HVAC heating system serving two solariums had malfunctioned weeks earlier, with only one repair estimate obtained and no timely notification made to OHCQ until the day surveyors arrived and discovered the lack of heat in the usual survey room.
The facility failed to prevent potential abuse or neglect during an active investigation when a GNA accused of neglecting a resident was allowed to return to work before the investigation was completed. Although the Administrator initially suspended the GNA and reported the allegation to the state agency, the GNA was brought back on duty while key RN witness statements were still being collected as part of the ongoing investigation. This resulted in the accused staff member resuming resident care responsibilities prior to the formal completion of the neglect investigation.
The facility failed to provide a written bed-hold notification to a resident or representative at the time of a hospital transfer following a fall, despite having a policy requiring that a bed-hold form be given whenever a resident is transferred out. In addition, the facility did not notify the local ombudsman in a timely manner about the discharges of two residents—one who was sent to the hospital and did not return and another who expired in the facility—with notifications instead occurring later by e-mail.
The facility failed to accommodate resident needs, as observed by surveyors. A resident was found without access to a call light, and another was left suspended in a Hoyer lift sling by a single staff member. The chapel was inaccessible due to storage, preventing services. A resident's call bell went unanswered for 25 minutes, and another was left waiting in a wheelchair for assistance. A resident expressed frustration over delays due to the unavailability of a Hoyer lift. The DON acknowledged these issues.
Surveyors observed multiple deficiencies in the facility, including damaged walls, hazardous power cords, and unclean environments in resident rooms and shower areas. A resident's room had a broken light fixture, and another had insects in the bathroom light. Staff interviews revealed awareness of these issues, but maintenance was limited by staffing constraints.
The facility failed to report abuse allegations and serious injuries within the required timeframe. Multiple residents experienced delayed reporting of abuse incidents, including rough care and mishandling of medical equipment. Additionally, a resident's serious injury was not reported to the State Survey Agency within the mandated 2-hour period, leading to a deficiency in timely reporting.
The facility failed to thoroughly investigate abuse allegations and prevent further potential abuse. Investigations into incidents involving several residents lacked interviews with other residents and formal statements from staff. Additionally, a GNA continued working after an abuse allegation without suspension. Other cases showed incomplete investigation files and missing interviews, indicating a pattern of inadequate response to abuse allegations.
The facility failed to develop and implement person-centered care plans for residents with specific medical needs, including epilepsy, chronic pain, seizures, and skin conditions. A resident with epilepsy did not have a care plan for their seizure disorder or medication monitoring. Another resident's care plan for chronic pain was outdated and did not include opioid use. A resident with a history of seizures lacked a seizure care plan despite experiencing seizures in the facility. Additionally, a resident with a pressure ulcer and fungal rash did not have a care plan addressing these conditions.
A resident was left waiting in a wheelchair for over 40 minutes due to the unavailability of a Hoyer lift, impacting their dignity and ability to participate in activities. The call bell system was also noted to alarm for long periods without response, as confirmed by the DON.
A facility failed to accurately assess a resident's seizure diagnosis during an annual survey. The resident, admitted with a history of seizures and prescribed lamotrigine, did not have seizures listed in the active diagnoses on the admission MDS assessment. The MDS Coordinator acknowledged the omission, attributing it to a potential data entry error.
A facility failed to accurately dispense and record oxycodone for a resident as per the scheduled ordered time. The resident's MAR showed that the medication was documented as given on time only twice between early and late November, with multiple instances of late documentation and two blank sign-offs. Interviews with staff revealed inconsistencies in documentation practices, and the DON acknowledged the discrepancies.
Multiple Failures in Medication Management, Order Implementation, and Behavior Monitoring
Penalty
Summary
The deficiency involves multiple failures to meet professional standards of quality related to medication security, protection of resident health information, implementation of physician orders, behavior monitoring, and medication administration. During early morning rounds on the first floor, a medication cart on B-Wing was observed unlocked and unattended, and an unlocked laptop displaying resident-specific information was left at the doorway of a resident room. During a medication pass with an RN, the medication cart and computer screen were repeatedly left open, unlocked, and unattended in various rooms and in the first-floor lobby, with resident information visible. On a later date, another medication cart on the second floor B-Wing was also observed open and unattended. The RN and an LPN both acknowledged that facility expectations require medication carts and computer screens to remain locked when not in use. Another deficiency involved failure to implement a physician order for a diagnostic test. A physician ordered a Complete Blood Count (CBC) for a resident with pneumonia to monitor the resident’s condition and guide treatment. A subsequent medical record review showed that this laboratory order was not carried out as written. The ADON explained that physicians enter lab orders, nurses transcribe them, and the 11:00 PM–7:00 AM shift is responsible for ensuring completion of lab tests unless the order is STAT. The ADON later confirmed that the CBC for this resident was not completed as ordered and stated that the reason for the failure was unknown. Additional deficiencies were identified in behavior monitoring and documentation for residents with psychiatric or behavioral diagnoses and those receiving psychotropic medications. One resident with depression, anxiety, and insomnia had an order for behavior monitoring every shift, and the TAR showed multiple dates and shifts with documented behavior frequencies, including a high number of behaviors on one date; however, there were no corresponding progress notes describing the types of behaviors or interventions used. Facility staff stated that when behaviors are documented on the TAR, it is the process to write a progress note describing the behaviors and interventions, and to complete an SBAR and notify the provider if behaviors persist or are new. The DON confirmed that progress notes should be written when behaviors escalate and that the TAR only records the number of episodes, not the behavior details, and could not explain the absence of progress notes for the documented behavior episodes. For another resident receiving Duloxetine, Escitalopram, and Olanzapine for depression and anxiety, review of the MAR showed that the medications were administered as ordered, but there was no documentation of behavior monitoring or effectiveness monitoring for the antipsychotic therapy. The ADON stated that effectiveness is to be monitored using behavior monitoring flow sheets and progress notes, but review of the record confirmed that no such documentation existed for this resident despite ongoing psychotropic use. A further resident with vascular dementia with psychotic disturbance, mood disturbance, and anxiety, and known behaviors such as yelling and screaming at others and a preference for personal space, had no documented behavioral assessment, no behavior monitoring tool in place, and no care plan interventions addressing these behaviors in the medical record. A separate deficiency involved improper medication administration when a resident was found with a Lidocaine patch on the mid-back that had been dated the previous day. The wound nurse identified the patch as a Lidocaine patch, but review of the resident’s medication orders and medical record revealed no physician order for a Lidocaine patch and no documentation of its application. The unit manager confirmed that the resident had a Lidocaine patch without a corresponding physician order, and the DON confirmed that the resident should not have had the patch because a physician order is required and administration must be documented on the MAR. The facility’s Nursing Policies and Procedures: Medical Management Program require documentation of medications administered according to state and federal requirements, including correct physician orders and diagnoses for each medication, and specify that for transdermal patches the application site must be documented and sites rotated, which was not done in this case.
Failure to Maintain Resident Dignity and Respectful Communication
Penalty
Summary
The deficiency involves failure to ensure resident dignity and respect for personal privacy and communication rights for two residents. In the first instance, a GNA entered a resident’s closed room without knocking or introducing herself while surveyors were present. When questioned immediately afterward, the GNA was unable to explain why she had entered without knocking or greeting the resident. The DON later confirmed that facility practice and expectations require all staff to knock, wait for a response or check for visitors, and then greet and introduce themselves and state their purpose every time they enter a resident’s room. In the second instance, a resident reported feeling mistreated and disrespected by a specific GNA who, according to the resident, communicated by pointing and using hand gestures instead of speaking. The resident stated this made him/her feel anxious, offended, and disrespected, and reported the concern to a family member, who then reported it to the facility. The facility’s investigation file documented that the resident’s POA reported the same concerns, and that the GNA acknowledged using both verbal and non-verbal communication, including hand gestures, with the resident. A psychiatric note documented that the resident felt anxious when a particular staff member provided care and that this staff member used hand gestures instead of verbal communication. The Administrator confirmed that the facility substantiated that the GNA used non-verbal communication with the resident, and acknowledged that this caused the resident to feel anxious, offended, and disrespected, constituting a dignity concern.
Unrepaired Ceiling Damage and Exposed Infrastructure in Laundry and Linen Areas
Penalty
Summary
The facility failed to ensure adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and safe environment, particularly in areas used for handling clean laundry and linens. During the annual survey’s Infection Control review, a surveyor observed a large hole in the ceiling of the laundry room in the clean clothes drying area, with exposed pipes, dust, and drywall. A similar large hole was observed in the ceiling of the clean linen folding room, also exposing pipes, dust, and drywall, with a ceiling fan located near the edge of the hole. These conditions were directly observed and photographed by the surveyor. In an interview, the Maintenance Director reported that there have been ongoing leaks in the building since 2014 and that leaks are repaired as they occur, but a full plumbing replacement has been delayed due to budget constraints and other priorities. He stated that the holes in the ceilings were created to access plumbing for repairs and confirmed that they remained open due to limited maintenance staffing, which prevented timely repair of the ceilings with drywall. The Maintenance Director verified that the holes in the laundry/dryer room ceiling were created the previous week for a leak repair and that the holes in the clean linen room ceiling were created in December for a separate leak. The Administrator acknowledged environmental concerns related to the ongoing leaks and resulting ceiling holes during an interview.
Failure to Timely Report Neglect Allegation and HVAC System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of neglect to the Office of Health Care Quality (OHCQ) within the required two-hour timeframe. A resident reported to the RN Unit Manager, with a Social Worker Assistant present, that a GNA had failed to change the resident’s brief after the resident requested assistance, instead covering the resident with a blanket and leaving. This interview occurred on 10/27/2025, and the resident indicated the incident had occurred approximately three weeks earlier, though the exact date was not recalled. The RN Unit Manager acknowledged that the resident reported the aide did not change him and that she spoke with the ADON after the interview. Despite this, the Administrator and ADON later stated they were not aware of the 10/27/2025 interview or the resident’s allegation at that time. The Administrator reported that he first became aware of the concern when he received a letter from the resident’s family member on 10/29/2025. Based on that letter, the Administrator submitted an allegation of abuse/neglect to OHCQ on 10/29/2025 at 1:39 PM. As a result, the allegation communicated by the resident on 10/27/2025 was not reported to OHCQ within two hours of the facility becoming aware of it, and the required initial report was delayed until two days later, after the family’s written complaint. A second deficiency concerns the facility’s failure to timely report a malfunction of the HVAC heating system to OHCQ. On survey entry, staff informed the survey team that the usual survey room (the B-wing solarium) did not have heat, and the team was relocated. Review of a Facility Reported Incident showed the HVAC failure in the B-wing solariums on two floors was not reported to OHCQ until the evening of the same day the survey team arrived. The NHA later stated that the HVAC system had malfunctioned in early November 2025 and that an estimate for repair had been obtained on 11/14/2025, but no additional estimates had been secured and the malfunction had not been reported to OHCQ at the time it occurred. The NHA acknowledged both the delay in obtaining required repair estimates and the delay in reporting the heating system malfunction to the State Agency.
Staff Returned to Work Before Completion of Neglect Investigation
Penalty
Summary
The deficiency involves the facility’s failure to prevent further potential abuse, neglect, exploitation, or mistreatment while an investigation into an allegation of neglect was still in progress. An allegation of neglect was reported involving Resident #61 and a Geriatric Nursing Assistant (GNA #5). The Administrator submitted the initial report of the allegation to the Office of Health Care Quality on 10/29/2025 and later submitted the final investigation report on 11/04/2025. Documentation showed that GNA #5 was suspended on 10/29/2025 following the allegation. Record review on 01/07/2026 revealed that the investigation file contained statements from the RN Unit Manager and RN #30, both dated 11/04/2025, indicating that investigative activities were still occurring on that date. During interviews, the Administrator confirmed that the investigation was completed on 11/04/2025 but also confirmed that GNA #5 had been allowed to return to work on 11/01/2025. When questioned, the Administrator stated that by 11/01/2025 he had determined the allegation could not be verified and therefore permitted the employee to resume work. Surveyors identified that because key witness statements were not obtained until 11/04/2025, the investigation was still ongoing when GNA #5 returned to work, meaning the staff member accused of neglect was allowed to resume duties before the investigation was completed.
Failure to Provide Bed-Hold Notice and Timely Ombudsman Discharge Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide required written bed-hold notification at the time of a resident’s transfer and failure to notify the local ombudsman of resident discharges. For one resident who fell while self-transferring from a wheelchair to a toilet and was subsequently transferred to the hospital via 911, the medical record contained a transfer summary and documentation that the family, on-call medical provider, and ombudsman were notified of the incident. However, there was no written copy of the facility’s bed-hold notification form in the resident’s medical record for that hospital transfer, despite facility policy requiring that a copy of the bed-hold form be given to every resident or representative at the time of transfer outside the facility. The deficiency also includes the facility’s failure to notify the local ombudsman of resident discharges in a timely manner for two residents. One resident was sent to the hospital and did not return, and another resident expired in the facility. Review of records and e-mails showed that the ombudsman was notified of these discharges and other discharges, hospitalizations, and admissions only later via e-mail, rather than at the time of the events. The Business Office Manager confirmed that the ombudsman had not been notified in a timely manner and stated she had not initially been aware that ombudsman notification was her responsibility.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of several residents, as observed by surveyors. One resident was found without access to a call light, which was out of reach behind the bed. This resident, a new admission, was noted to have demonstrated appropriate use of the call bell previously. Another resident was left suspended in a Hoyer lift sling by a single staff member, who was waiting for additional assistance, contrary to the requirement for two staff members during such transfers. The Director of Nursing (DON) acknowledged these issues and confirmed that the call light should have been within reach and that the resident should not have been left unattended in the sling. The surveyors also noted that the facility's chapel was inaccessible to residents due to storage of beds and other items, preventing scheduled chapel services. Additionally, a resident's call bell was observed blinking for 25 minutes without response, and another resident was left in a wheelchair in the hallway waiting for assistance to be transferred to bed. The DON was informed of these issues and acknowledged the delay in responding to call bells, attributing it to a staff callout. Another resident expressed frustration over delays in assistance due to the unavailability of a Hoyer lift, which was necessary for their transfers. This resident was found waiting for over 40 minutes for assistance back to bed, with their call bell alarming. The resident reported frequent delays in receiving care and being unable to participate in activities due to these issues. The DON and administrative support eventually assisted the resident, and the surveyor noted the resident's dependency on a wheelchair and mechanical lift for mobility.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as observed by surveyors. In Resident #40's room, there was extensive paint damage on the walls, a Geri-chair with tattered armrests, and a mattress air flow device with a power cord that posed a tripping hazard. Resident #67's room had stained bed linens, a plastic urinal on the floor, and meal trays with leftover food and debris. Additionally, the shower and bathing environments in the facility had several issues, including broken tiles, rust-like substances, and soiled drapes. Further observations revealed that Resident #24's room had a television mounted with a power cord suspended in mid-air, creating a potential hazard. Resident #85's bathroom had a ceiling light fixture filled with insects, and Resident #542's room had a broken light fixture and non-functioning sink lights. The surveyors also noted a mold-like substance around the fire alarm in the hallway ceiling, indicating previous leaks that had not been addressed. Interviews with facility staff, including the Maintenance Director and Housekeeping Director, confirmed awareness of these issues. The Maintenance Director acknowledged the hazards and stated that maintenance requests were logged at the front desk or nurses' station. However, there was a reliance on nursing staff to report issues, and with only two maintenance staff members, prioritization was necessary. The Housekeeping Director confirmed that cleaning was done daily, but some areas, like light fixtures, were the responsibility of maintenance.
Failure to Timely Report Abuse and Injuries
Penalty
Summary
The facility staff failed to timely report allegations of abuse to the State Agency, the Office of Health Care Quality (OHCQ), within the required timeframe of 2 hours after the abuse allegation was made. This deficiency was evident in multiple cases involving residents. For instance, in the case of one resident, the Assistant Director of Nursing (ADoN) documented the incident time, but the self-report was sent 2 hours and 37 minutes later than required. In another case, the Director of Nursing (DoN) documented an incident but failed to report it for more than 19 hours. In another instance, a resident accused a Geriatric Nursing Assistant (GNA) of hitting them with a pillow, but the facility did not report the allegation to the OHCQ until several days later, following a grievance form submission. Additionally, a resident reported rough care and mishandling of their enteral feeding tube, but the facility did not report the allegation until surveyors brought it to the attention of the DoN. The ADON admitted to not reporting the allegation due to the resident's history of complaints. Furthermore, a resident sustained a serious injury, a fracture of the left femur, which was not reported to the State Survey Agency within the required 2-hour timeframe. The facility received the radiology report indicating the fracture, and the resident was transferred to the hospital for surgical intervention. However, the facility reported the injury to the State Survey Agency the following day, exceeding the reporting timeframe. The DoN mistakenly believed they had 24 hours to report the incident.
Inadequate Investigation and Response to Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate alleged violations of abuse and prevent further potential abuse while investigations were in process. In the case of Resident #91, the facility did not conduct interviews with other residents who were under the care of the alleged perpetrator, GNA Staff #39, to verify if there were additional concerns. Similarly, for Resident #108, the investigation lacked interviews with other residents cared for by GNA Staff #38, and no formal written statements were obtained from staff, only summaries. The facility also failed to suspend GNA Staff #38 pending the outcome of the investigation into the alleged abuse of Resident #108. Despite the allegation being reported, Staff #38 continued to work shifts, and there was no documentation of suspension or termination related to the abuse allegation. The investigation was deemed incomplete as it did not include statements from other residents or staff who interacted with the alleged perpetrator. Additional deficiencies were noted in other investigations, such as the case of Resident #2, where the facility failed to provide a complete investigation file for a reported incident of missing funds. In another instance, the investigation into an injury of unknown origin for Resident #19 did not include interviews with the resident or their family, nor with other residents. Similarly, the investigation of an alleged abuse involving Resident #93 lacked interviews with the resident and other residents cared for by the alleged perpetrator, GNA #9. These deficiencies highlight a pattern of incomplete investigations and inadequate measures to prevent further potential abuse.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for several residents, leading to deficiencies in addressing their specific medical needs. Resident #60, who was admitted with a diagnosis of epilepsy and was taking anticonvulsant medication, did not have a care plan addressing their seizure disorder or the use and monitoring of the medication. This oversight was confirmed by the MDS Coordinator, who acknowledged that the resident should have been care planned for epilepsy due to their medication regimen. Resident #65, admitted with chronic pain syndrome and prescribed opioids for pain relief, had a care plan for pain that was outdated and did not include the use and monitoring of the narcotic analgesics. The care plan had not been revised since November 2023, despite changes in the resident's medication orders. The Director of Nursing was informed of the concern regarding the development and implementation of care plans for residents. Resident #96, who had a history of seizures resulting from a stroke and was actively being treated with lamotrigine, did not have a seizure care plan in place. This was despite the resident experiencing seizures while in the facility, which required medical intervention and hospitalization. Additionally, Resident #64, who had a pressure ulcer and a fungal rash, did not have a care plan addressing these conditions, even though they were documented and treated. The Director of Nursing was unable to provide a care plan that included these issues when requested by surveyors.
Failure to Maintain Resident Dignity and Timely Assistance
Penalty
Summary
The facility failed to maintain and enhance the dignity of its residents, as evidenced by the situation involving Resident #81. During an annual survey, it was observed that the resident was left sitting in a wheelchair with a Hoyer pad underneath for over 40 minutes, waiting for assistance to be transferred back to bed. The resident's call bell was alarming, indicating a need for help, but the response was delayed. The resident expressed dissatisfaction, stating that finding a Hoyer lift is a recurring issue, leading to prolonged waiting times for assistance. This situation prevented the resident from participating in activities and receiving timely morning care. The Director of Nursing (DON) and Administrative Support were eventually observed assisting the resident back to bed. The surveyor informed the DON of the resident's concerns, including the persistent issue of call bells alarming for extended periods without response. The DON confirmed the problem, highlighting a systemic issue with the facility's response to residents' needs and the availability of necessary equipment like the Hoyer lift.
Failure to Accurately Assess Resident's Seizure Diagnosis
Penalty
Summary
The facility failed to accurately assess a resident, identified as Resident #96, during an annual and complaint survey. The resident was admitted to the facility in late February 2023 with a medical history that included difficulty walking, muscle weakness, seizures, and a cerebral infarction (stroke). The hospital admission history from January 31, 2023, noted seizures resulting from an anterior cerebral artery stroke, and the resident was prescribed lamotrigine to prevent seizures. However, during the review of the resident's admission Minimum Data Set (MDS) assessment completed on February 22, 2023, seizures were not listed among the active diagnoses. The surveyor interviewed the MDS Coordinator, who explained that conditions and diagnoses are coded by reviewing the admitting diagnosis, discharge summary, and medications ordered. Despite the presence of a seizure diagnosis in the hospital discharge paperwork and a corresponding medication order, seizures were not coded on the resident's admission MDS assessment. The MDS Coordinator acknowledged the omission and suggested it could have been a data entry error, although the condition was included in the discharge assessment.
Medication Administration and Documentation Deficiency
Penalty
Summary
The facility failed to accurately dispense and record medications as per the scheduled ordered time for a resident who was prescribed oxycodone for pain management. The resident was admitted in early November 2022 and had an order for oxycodone 5 mg every 6 hours as needed for pain. On November 7, 2022, the Medical Director evaluated the resident and ordered routine oxycodone to be given at 7 AM along with the as-needed dose. However, the Medication Administration Record (MAR) review revealed that from November 8 to November 30, 2022, the scheduled oxycodone was documented as given on time only twice. There were multiple instances of late documentation, and on two occasions, the sign-off for the scheduled oxycodone was blank. Interviews with staff revealed inconsistencies in the documentation practices. An LPN stated that she charts the administration shortly after giving the medications in the MAR. The Director of Nursing (DON) acknowledged the discrepancies in the MAR documentation and noted that the delayed documentation was done by multiple staff members. The DON also mentioned that she was not in her current role at the time of the incidents and could not comment on the documentation practices during that period.
Latest citations in Maryland
The facility did not ensure that its Infection Preventionist (IP) met required qualifications for managing the Infection Prevention and Control Program. The DON reported serving as the IP but acknowledged lacking the specialized infection control training required for the role, and confirmed that no other staff member was currently qualified. Records showed that the previously qualified IP left several months earlier, and the Administrator and DON confirmed they were still seeking a replacement, leaving the infection control program without a properly trained leader.
Staff failed to consistently secure medications and medical supplies across three units, including an oxygen tank left on the floor behind a resident’s bed without a supporting device, a treatment cart with Collagenase Santyl cream left on top while two residents in power wheelchairs passed by, an unattended and unlocked treatment cart at a nursing station, and another treatment cart with Diclofenac gel and dressings left on top, indicating repeated lapses in maintaining locked and secure storage for drugs, biologicals, and related supplies.
The facility failed to provide sufficient dietitian coverage and timely nutritional assessments for several residents with significant dietary needs. A resident admitted for diabetic management with a high A1C was placed on a regular diet instead of the recommended carb-controlled diet and had only one weight taken in the first two weeks, with no dietitian review of the record. Another resident with prior significant weight loss had no documented dietitian follow-up despite continued weight loss, and a resident admitted with severe protein-calorie malnutrition experienced further significant weight loss without any dietitian assessment. The dietitian reported working limited hours and prioritizing certain high-risk cases, resulting in delayed or missed evaluations for new admissions and residents with ongoing nutritional concerns.
The facility failed to maintain adequate linen and incontinence supplies and did not keep resident care areas in good repair, resulting in delays and alterations in incontinence care and substandard environmental conditions. Staff reported that towels and washcloths were used instead of wipes and then discarded due to heavy soiling, and that linen deliveries to units were late, leaving residents waiting for care. Observations showed very limited numbers of clean washcloths and other linens on units and in the laundry, with no stock of disposable wipes or backup washcloth supply despite repeated reports to housekeeping. Additional observations revealed recliner chairs blocking a dining-area handwashing sink and kitchenette, multiple resident and shared bathrooms with unfinished spackle, chipped paint, musty odors, black substances near showers, missing threshold molding, exposed cracks and nails, and eroded, rusted baseboard heaters. Hallway handrails on both units were worn, chipped, and splintered, and a shower room contained fecal odors, dried brown stains on the toilet, and deteriorated fixtures, all contributing to a failure to provide a safe, clean, and homelike environment.
Facility staff did not thoroughly investigate two separate abuse allegations involving a resident and an injury of unknown origin involving another resident. In both cases, investigations focused on the directly affected resident and included staff interviews, but there were no interviews of other residents on the unit or documented assessments of those residents for signs of abuse or injuries of unknown origin, including residents unable to communicate due to cognitive status.
Two residents who were dependent on staff for oral care, including one with a tracheostomy, were observed with thick, white or milky substances coating their mouths and teeth, indicating inadequate oral hygiene. One resident communicated that staff did not brush their teeth and that staff "need to." In another case, despite oral care supplies being present in the room, the resident’s mouth and teeth remained unclean on multiple observations, with a thick milky substance caking the teeth and stringing between them when the resident tried to open their mouth. These findings showed that staff did not consistently provide oral care to residents who relied on them for this ADL.
Staff failed to maintain complete and accurate medical records for multiple residents, including missing and inconsistent documentation of wound care, delayed pain assessment after discovery of an injury of unknown origin in a cognitively impaired resident, and inaccurate recording of a PPD test result that was documented as negative despite no evidence the injection was administered and no supporting nurse’s note. Residents reported not receiving certain treatments, while MAR entries either lacked signatures for completion or contained conflicting information about whether care was provided.
Surveyors found that the facility failed to consistently implement and communicate correct transmission-based precautions and PPE use. One resident with a Foley catheter related to wounds had no precaution signage posted, while another resident in a double room had a contact precautions sign at the door, yet the NP entered without PPE and the GNA provided high-contact care wearing only gloves. Staff in that room stated the resident was not on contact precautions and later reversed the sign to show no PPE requirement. Therapy staff reported they rely solely on posted signs to determine PPE, and surveyors identified broader issues with inaccurate signage and staff awareness of which residents required contact precautions.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Unqualified Infection Preventionist Overseeing Infection Control Program
Penalty
Summary
The facility failed to ensure that its designated Infection Preventionist (IP) met the mandatory qualifications for overseeing the Infection Prevention and Control Program. During an interview on 3/24/26 at 10:00 AM, the DON confirmed that she/he was serving as the facility’s IP but had not completed the specialized training in infection control required for the position. The DON further stated that no other staff member currently met the qualifications to serve as IP. Record review showed that the previously qualified IP left the facility in October 2025, and as of the survey date, the position remained unfilled by a qualified individual. At 1:30 PM on the same day, the Administrator and DON confirmed they were still in the process of finding a qualified IP for the facility, leaving the Infection Prevention and Control Program without a properly trained and qualified leader. No specific residents, medical histories, or clinical conditions were described in relation to this deficiency.
Unsecured Medications, Treatment Carts, and Oxygen Equipment
Penalty
Summary
Facility staff failed to ensure that drugs, biologicals, and related medical supplies were securely stored and properly maintained on multiple units. On one unit, an oxygen tank assigned to a resident was observed sitting on the floor behind the resident’s bed without any supporting device. On another unit, a treatment cart was observed with a tube of Collagenase Santyl cream labeled for a specific resident left on top of the cart, while residents in power wheelchairs passed by and staff were present at the nursing station. These observations showed that medications and oxygen equipment were not consistently secured as required. Further observations on additional units revealed an unattended and unlocked treatment cart at a nursing station, and on a separate occasion, a treatment cart with Diclofenac gel labeled for a resident left on top along with multiple packs of dressings. These incidents occurred across three units and on more than one date, demonstrating repeated failures to keep medications and treatment supplies in locked compartments or otherwise secured from unauthorized access.
Insufficient Dietitian Coverage and Delayed Nutritional Assessments
Penalty
Summary
The deficiency involves the facility’s failure to employ sufficient food and nutrition staff, including adequate dietitian coverage, to ensure timely assessment and appropriate diets for residents with significant nutritional and diabetic needs. A resident admitted over two weeks earlier with multiple comorbidities and an A1C of 11.5% had a hospital discharge recommendation for a carbohydrate-controlled diet, but was placed on a regular diet at admission with no acknowledgment of the recommended diet until one week later, when the resident requested larger portions. As of the survey date, the dietitian had not yet seen or reviewed this resident’s medical record, and the resident reported not having seen a dietitian and being very frustrated with the meals. During the first two weeks after admission, only one weight was obtained for this resident, despite physician notes stating the resident’s weight was “stable.” Further review of other residents showed additional failures in timely dietitian assessment and follow-up. One resident, readmitted in January and previously seen by the dietitian in September for a 6.4 lb weight loss over 30 days, had no documented follow-up despite continued weight loss totaling 22 lbs since the last dietitian review. Another resident admitted at the end of February with severe protein-calorie malnutrition had not been seen by the dietitian after about a month in the facility, despite a documented 14 lb (7%) weight loss over two weeks. The dietitian reported working only 12 hours per week at the facility and stated that she must prioritize which residents to see, focusing first on residents with tube feedings and those identified in risk meetings, resulting in delayed or absent assessments for new admissions and residents with ongoing weight loss and malnutrition diagnoses.
Linen Shortages and Poor Environmental Maintenance Compromise Resident Care and Comfort
Penalty
Summary
The deficiency involves the facility’s failure to maintain an adequate supply of clean linens and appropriate incontinence wipes, resulting in delays and alterations in residents’ incontinence care, as well as the use of towels and washcloths in place of disposable wipes. During the initial tour, the surveyor observed that the linen supply on one nursing unit hallway was low. Complaint reviews included concerns about delays in incontinence care and bed linens not being changed regularly, with residents left without clean bedding. A complainant reported that there was not enough clean linen available for residents. Staff interviews confirmed that towels, sheets, and washcloths were being used to wipe residents for incontinence care due to the absence of wipes, and that many of these linens were being thrown away when soiled. Staff also reported a shortage of linen, that linen deliveries to the units were late, and that residents who preferred to get up before breakfast had to wait for care when linen was delayed. Further observations showed that the clean supply room contained no disposable wipes or cloths for incontinence care, and a resident reported that staff did not use wipes, that the resident had to purchase their own, and that heavily soiled towels or washcloths were discarded. A tour of all nursing unit linen carts and closets revealed only six clean washcloths and limited supplies of towels, gowns, and bed linens. In the laundry room, only three washcloths were present, and the laundry assistant stated that there were only three washcloths available for each nursing unit that morning, that the facility was short on linen supply, and that these concerns had been repeatedly reported to the Director of Housekeeping over the preceding month and again that morning. The laundry assistant confirmed there was no additional laundry in process. The DON stated that wipe squares should be used for incontinence care, but no such wipes were found in the clean medical supply room, and no backup supply of washcloths was present in the emergency linen supply. The Director of Housekeeping confirmed there was no backup supply of washcloths. The deficiency also includes environmental and maintenance issues affecting resident bathrooms, handrails, and common areas. In the main dining area, a recliner chair was observed positioned directly in front of the handwashing sink, and two recliner chairs were stored in front of the nutrition area kitchenette. Multiple resident bathrooms and shared bathrooms were repeatedly observed over several days with unfinished spackle on walls that needed resurfacing and painting, chipped paint around sinks, uneven boards nailed to walls under sinks that appeared to partially cover holes, musty odors, black substances between shower bases and walls, missing threshold transition molding exposing cracks, missing tiles, and a nail, as well as eroded and chipped paint on baseboard heaters with exposed dark brown metal and rust-like material. Hallway handrails on both nursing units were observed to be worn, with chips, splintering, holes, and areas where the wood finish had worn off. A shower room was observed with a foul fecal odor, dried brown stains on the back of the toilet seat and in the toilet bowl, and a baseboard heater with eroded, chipped paint and rust-like material, along with chipped paint on the handrail. These conditions were acknowledged by the Director of Maintenance and other leadership, and some areas were noted to be in the process of renovation, but the observed deficiencies remained present during the survey period. Overall, the facility did not maintain a safe, clean, comfortable, and homelike environment in good repair across both nursing units and the dining area. The lack of adequate linen and incontinence supplies, combined with the poor condition of resident bathrooms, handrails, and certain common areas, constituted the basis for the cited deficiency. The observations and staff and resident reports consistently described shortages of essential hygiene supplies, delayed care related to linen availability, and multiple unresolved environmental and maintenance issues in resident care areas and shared spaces.
Failure to Thoroughly Investigate Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
Facility staff failed to thoroughly investigate allegations of potential abuse involving one resident and an injury of unknown origin involving another resident. For one resident, there were two separate allegations of abuse occurring on different days in early February. The facility’s investigation packets included interviews with staff who cared for or were scheduled to work with this resident on the days of the alleged incidents, and the investigations focused solely on this resident. However, there were no interviews conducted with other residents on the unit to inquire about abusive or neglectful treatment by the staff who were working during the times of the allegations. The surveyors noted that, although the allegations were not validated, there was no documentation that other residents were interviewed, if able, or assessed for signs or symptoms of injury. In a separate incident, another resident was identified on March 4 with a new bruise on the right eye, documented as a change in condition at 4:09 AM. This resident had a BIMS score of 99, indicating the resident was unable to complete an interview and therefore could not report how the injury occurred. The facility’s investigation identified a potential cause of the injury but did not reach a definitive resolution. Additionally, there were no interviews of other residents on the unit regarding possible abuse, nor were there documented assessments of other residents for injuries of unknown origin, particularly for those unable to speak for themselves, as in this resident’s case.
Failure to Provide Oral Care to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide oral care to residents who were dependent on staff for activities of daily living, specifically oral hygiene. One resident with a tracheostomy was observed with a thick, sticky white substance in the mouth and was noted to intermittently chew on nearby bedding. This resident made good eye contact and, when asked if staff brushed their teeth, shook their head no and mouthed that staff “need to.” According to the resident’s Minimum Data Set (MDS) dated 2/11/26, the resident was dependent on staff for oral care. Another resident, also dependent on staff for oral care per the 3/11/26 MDS, was observed sitting propped up in bed and able to respond with smiles. During the initial observation, the inside of this resident’s lips and upper and lower teeth had a thick, clear, white milky substance visible when the resident tried to open their mouth to smile. Oral care supplies were present in the nightstand, but the resident’s mouth and teeth were not clean. On a subsequent observation with the DON, NHA, and Corporate VP of clinical services, the same resident again had a thick, clear, milky substance between the lips and caking the teeth, which would string between the teeth when the resident attempted to open their mouth, demonstrating a lack of consistent oral care for residents dependent on staff for this ADL.
Incomplete and Inaccurate Medical Record Documentation for Treatments and Assessments
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and documentation for multiple residents. For one resident with wound care needs, review of the MAR showed that wound care and related treatments were signed as completed on the dates initially reported, despite the resident’s ongoing complaints that wound dressings were not being changed. When additional dates were reviewed, there were missing staff signatures for wound care on two specific dates, as well as three instances where application of A&D ointment to the resident’s feet was not signed off out of 24 days reviewed. Another resident with severe cognitive impairment, as evidenced by a BIMS score of 00, was found to have an injury of unknown origin (a bruise on the left hand). Documentation showed that a change in condition was initiated late in the morning, but a formal pain evaluation was not initiated and completed until that night, and the resident was unable to explain how the injury occurred or verbalize pain using a standard pain scale. For a third resident, documentation related to the admission PPD test was inconsistent and incomplete. The MAR contained an entry indicating “9” for the administration date, meaning “see nurse’s note,” but there was no corresponding nurse’s note. Despite the absence of a signed administration of the PPD injection, staff documented the PPD result as “negative” on the scheduled read date. The resident reported never receiving the PPD injection, and the DON confirmed that the facility had been out of PPD solution at the time, so the test would not have been administered. These findings demonstrate failures in accurate documentation of treatments and assessments, including wound care, pain assessment, and TB screening, as well as missing or incomplete supporting notes in the medical record.
Failure to Implement and Communicate Correct Transmission-Based Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to inconsistent and incorrect implementation of transmission-based precautions and PPE use. During a complaint investigation focused on residents on transmission-based precautions, one resident with a visible Foley catheter was observed in the room with physical therapy, but there were no signs posted indicating any need for PPE, despite the resident being a new admission with a Foley catheter placed related to wounds. In another double-occupancy room, a contact precautions sign was posted at the doorway, but the nurse practitioner was in the room on a personal phone with no PPE, and the assigned GNA was repositioning the resident in bed while wearing only gloves. When questioned, the NP, RN, and GNA all stated that the resident in the room was not on contact precautions, and the GNA reported that signs were hanging at all doors and that this particular resident’s sign was “just wrong.” The surveyor observed the GNA later return to the room and turn the sign around to indicate no PPE requirement. Subsequent interviews revealed that therapy staff relied on posted signage to determine PPE use and that if the sign was wrong, the PPE used would be wrong. Overall, surveyors found problems with signage accuracy and staff awareness of which residents required contact precautions, as well as observed failures to follow appropriate PPE use for residents who should have been on contact precautions.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
