Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Wilson Health Care Center during CMS and state inspections, most recent first.
Unauthorized Disclosure of Resident Medical Record: An LPN inadvertently gave a resident’s daughter the wrong chart during a dental appointment, resulting in another resident’s medical record being disclosed. The resident involved had severe cognitive impairment, with a BIMS score of 0 out of 15. The facility’s investigation confirmed the incorrect chart was handed over in error while the resident was being transported to the appointment.
Failure to provide scheduled showers: A resident who preferred showers over bed baths was scheduled for twice-weekly showers, but records and staff interview showed the resident was not actually showered as documented. The resident’s representative reported the resident had not been showered in a long time, and the DON confirmed showers were expected unless refused, with refusals to be documented.
Call bells were not kept within reach for two residents observed during a survey. One resident’s call bell was found on the floor and the resident could not locate it, while another resident’s call bell was also on the floor after the resident had gone to therapy. Staff stated that call bells should be kept accessible and were unsure why one had not been returned to the resident’s reach.
Staff failed to accurately document medication side effect monitoring, with required 'Y' or 'N' entries and corresponding progress notes often missing or replaced by check marks. Errors were also found in residents' medical records, including incorrect hospitalization dates and incomplete advance directive documentation lacking dates and witness signatures. These deficiencies affected several residents receiving medications requiring close monitoring and those with advance directives.
A resident's Advance Directive was found to be incomplete, missing essential information such as the effective date, witness signatures, and completion of the organ donation section. Both the Administrator and Social Worker acknowledged the missing elements when presented with the document during the survey.
A resident reported a missing credit card, which was later found to have been stolen and used multiple times without authorization. Facility investigation confirmed the misappropriation of the resident's property, and the Nursing Home Administrator verified the theft during a surveyor interview.
A resident with a history of falls and balance issues experienced multiple falls related to a broken wheelchair brake and noncompliance with locking the brake. Despite these incidents, staff did not update the care plan to address the use of the wheelchair and brake compliance until months after the initial falls. The DON acknowledged the need for a behavioral care plan but could not explain the delay in updating the care plan.
A resident experienced multiple falls due to a malfunctioning wheelchair brake that was not promptly repaired or flagged for maintenance. Staff interviews revealed that equipment concerns are reported through a work order system, but there was no proactive equipment safety assessment or documentation for the resident's personal wheelchair. Another unoccupied wheelchair was also found with a similar brake issue.
A resident's call bell was found out of reach on multiple occasions, including behind a bookcase and on the floor, leaving the resident unable to call for assistance and relying on staff to check in. The charge nurse confirmed awareness of the issue and had previously returned the call bell to the resident.
The facility failed to implement comprehensive abuse prevention policies, lacking procedures for staff training and coordination with the QAPI program. The NHA confirmed these deficiencies and planned to inform the corporate office.
Facility staff failed to timely report an injury of unknown origin for a resident with severe cognitive impairment. The resident was found with a discolored, swollen leg and a fractured foot was later confirmed by x-ray. The report to the State Agency was delayed, and the LPN on duty did not report the injury to a supervisor. The DON acknowledged the oversight and provided disciplinary action and education to the LPN.
A facility failed to thoroughly investigate an abuse allegation involving a resident who relied on staff for daily activities. The incident involved a staff member allegedly slapping the resident's hand and removing the call bell. The investigation did not include interviews with all relevant staff or verify details with the nursing staff who interacted with the resident that morning. The Nursing Home Administrator noted that the Unit Manager responsible for the interviews was unavailable for further clarification.
A resident with a history of sepsis and UTI did not receive a physician-ordered IM injection of Rocephin due to a failure in medication administration and documentation. The LPN initially claimed to have administered the medication but later admitted it was not given. The facility's Pyxis system showed no record of the medication being dispensed, and the resident's MAR lacked documentation of administration. Despite this, the resident later received IV Rocephin through a PICC line.
During a COVID-19 outbreak, staff on one floor of the facility failed to wear masks as required. A GNA was observed without a mask in a dining area, and another GNA removed her mask while sitting at the same table. Additionally, a Housekeeping Aid was seen without a mask in a common area. The DON confirmed that mask-wearing was mandatory in resident care areas, but staff did not comply despite receiving education on the requirement.
Unauthorized Disclosure of Resident Medical Record
Penalty
Summary
The facility failed to ensure the confidentiality and protection of a resident’s medical record from unauthorized disclosure. During a dental appointment, an LPN inadvertently provided the wrong resident’s chart to the daughter of Resident #138, who was accompanying the resident. The daughter later identified that the chart did not belong to her family member and returned it to the LPN. The facility’s investigation documented that the incorrect chart had been handed over in error while the resident was being transported to the in-house dental appointment. Resident #138 had severe cognitive impairment, with an MDS showing a BIMS score of 0 out of 15 at the time of the incident. The DON stated that the consulting dentist did not rely on the paper chart because electronic access to the resident’s record was available, but the facility’s practice at the time was to send paper charts with residents to appointments. The investigation materials also included a staff statement acknowledging the mistake and confirming that the incorrect chart had been given to the resident’s daughter.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide dependent residents with showers for Resident #18, who was scheduled to receive showers twice weekly and whose preference evaluation indicated a preference for morning showers. The resident’s representative reported that the resident preferred showers over bed baths, but the resident had not been showered in a long time. Review of the care plan and progress notes did not show that the resident refused showers. Record review showed that Staff #9 documented showers for Resident #18 on 4/6/26, 4/10/26, 4/13/26, 4/16/26, and 4/20/26, but no showers were documented for 4/2/26, 4/3/26, 4/9/26, 4/17/26, 4/23/26, 4/24/26, and 4/27/26. During interview, Staff #9 stated she had not showered the resident during the month of April and clarified that she had provided bed baths only while documenting the task as showers.
Call Bells Not Within Reach
Penalty
Summary
The facility failed to ensure that residents had call bells within reach, as observed for two residents out of 10 randomly selected residents on the unit during the recertification survey. Resident #122 was observed with the call bell on the floor, and when asked where it was, the resident looked around the bed and stated they did not see it. Staff #14 stated that it is staff responsibility to keep resident call bells within reach at all times and, during the room observation, indicated the call bell should have been clipped to the resident’s bed for accessibility. Resident #181 was also observed with the call bell on the floor, and Staff #15 stated the resident was in therapy and was unsure why the call bell had not been returned to within the resident’s reach. The DON was made aware of the observations and concerns.
Failure to Accurately Document and Maintain Resident Medical Records
Penalty
Summary
Facility staff failed to accurately document and maintain medical records in accordance with accepted professional standards for multiple residents. In several cases, staff did not properly record whether residents exhibited side effects from anti-anxiety, antipsychotic, antidepressant, and anticoagulant medications. Instead of using the required 'Y' or 'N' documentation to indicate the presence or absence of side effects, staff sometimes used check marks or failed to provide the necessary progress notes when side effects were indicated. This was observed in the records of residents with diagnoses such as dementia, anxiety, depressive disorder, and those receiving medications that require close monitoring for adverse effects. Additionally, there were discrepancies and errors in the documentation of residents' medical status. For example, one resident's Treatment Administration Record did not reflect the required observation status for antipsychotic medication monitoring, and another resident's progress note incorrectly stated a recent hospitalization that did not match the actual hospitalization date provided by the DON. These inaccuracies resulted in medical records that did not accurately reflect the residents' current status or medical history. The facility also failed to ensure that advance directive documentation was complete and accurate. In one instance, a resident's advance directive was missing essential information such as dates and witness signatures, despite a progress note indicating the document had been completed and filed. These deficiencies were identified through medical record reviews and staff interviews, where staff acknowledged the documentation errors and omissions.
Incomplete Advance Directive Documentation
Penalty
Summary
Facility staff failed to ensure that a resident's Advance Directive (AD) was fully completed. Upon review of the resident's paper chart, it was found that the AD lacked critical information, including the effective date of the designated health agent's power, a date on the resident's signature, and signatures and dates for two required witnesses. Additionally, the organ donation section of the AD was incomplete, and the witness signature and date fields were left blank. The deficiency was identified during a survey when the surveyor reviewed the resident's AD and brought the missing information to the attention of the facility's Administrator and Social Worker. Both acknowledged the incompleteness of the document. The incomplete AD was present in the resident's record at the time of the survey, and there was no indication that the required signatures and information had been obtained prior to the surveyor's review.
Failure to Prevent Misappropriation of Resident Property
Penalty
Summary
A deficiency was identified when a resident reported to the Nursing Home Administrator that their credit card was missing, and it was subsequently discovered that the card had been used four times without authorization on the previous evening. A review of the facility's investigative file confirmed that the credit card was stolen and used at various stores. The facility's investigation verified the misappropriation of the resident's property through theft and unauthorized use of the credit card. The Nursing Home Administrator confirmed the occurrence of this misappropriation during an interview with the surveyor. This incident was one of five facility-reported incidents reviewed during the survey and was substantiated through both record review and staff interviews.
Failure to Timely Update Care Plan After Repeated Wheelchair-Related Falls
Penalty
Summary
Facility staff failed to update a resident's care plan to address repeated falls involving the use of a wheelchair with a broken brake lever. The resident, identified as high fall risk due to balance issues and a history of falls, experienced multiple falls over several months, some of which were directly related to the malfunctioning wheelchair and noncompliance with locking the wheelchair brake. Documentation showed that the resident reported the broken brake lever and that falls occurred when the wheelchair brake was not engaged, resulting in the wheelchair moving unexpectedly during transfers. Despite these incidents, the resident's care plan was not revised to address the specific risks associated with the wheelchair and the resident's compliance with brake usage until several months after the initial falls. The Director of Nursing acknowledged that the resident should have had a behavioral care plan addressing noncompliance with locking the wheelchair brakes but could not explain why the care plan was not updated following earlier falls. The lack of timely care plan revision contributed to the ongoing risk of falls for the resident.
Failure to Ensure Wheelchair Safety and Timely Equipment Assessment
Penalty
Summary
Facility staff failed to ensure the safety of a resident's wheelchair, resulting in multiple falls for the resident. The resident reported that the brake lever on their wheelchair was broken, which was confirmed by a surveyor's assessment showing that the right brake lever did not fully lock the wheel, allowing movement. The left brake lever functioned properly. The resident experienced several falls on documented dates while attempting to stand up or sit down using the wheelchair. Additionally, another unoccupied wheelchair in the facility was found to have a similar issue with its right brake lever. There were no visible indicators, such as tickets or signs, to show that the wheelchairs required repair. Interviews with staff revealed that nursing staff are responsible for reporting equipment concerns, which are then submitted as work orders through a designated system. However, the maintenance technician does not proactively check equipment and only addresses issues based on submitted reports. The Director of Nursing was unable to provide documentation that the resident's personal wheelchair had been assessed for safety hazards upon admission or prior to use in the facility.
Resident Call Bell Not Accessible
Penalty
Summary
Facility staff failed to ensure that a resident's call bell was within reach on multiple occasions. On one observation, the call bell was found hanging behind a bookcase at the foot of the resident's bed, making it inaccessible. When asked how they would call for assistance, the resident was unable to locate the call bell and stated they would wait until someone checked on them. On a subsequent observation, the call bell was found on the floor on the left side of the bed, again out of the resident's reach. The charge nurse confirmed having previously found the call bell behind the bookcase and returned it to the resident, indicating a repeated issue with call bell accessibility for this resident.
Deficiency in Abuse Prevention Policies
Penalty
Summary
The facility failed to develop and implement comprehensive abuse prevention policies to ensure resident safety. During the investigation of a reported incident, a review of the facility's abuse prevention policies and procedures revealed deficiencies. The policy, dated 11/13/24, lacked procedures for training new and existing staff, those with contractual agreements, and volunteers on their expected roles. Additionally, there was no policy or procedure to establish coordination with the Quality Assurance Performance Improvement (QAPI) program. The Nursing Home Administrator (NHA) confirmed the absence of these elements in the policies and procedures and acknowledged the need to inform the corporate office.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
Facility staff failed to recognize and report an injury of unknown origin within the required time frame for a resident with severe cognitive impairment. The resident, who had a care plan for fall risk due to dementia and lack of safety awareness, was found by an LPN with a discolored, swollen left lower leg and a blister on the left great toe. An x-ray later revealed a fractured foot. The facility became aware of the injury upon receipt of the x-ray results, but the report to the State Agency was delayed until the following day. Interviews conducted during the investigation revealed that the LPN on duty at the time of the x-ray report did not report the injury as an unknown origin to a supervisor. The Director of Nursing acknowledged this oversight and indicated that disciplinary action and education were provided to the LPN. The geriatric nursing assistant assigned to the resident on the day of the incident could not recall the specific event but noted the resident's tendency to reposition themselves in bed. The Nursing Home Administrator confirmed the absence of key staff members involved in the incident during the investigation.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to ensure a thorough investigation of an abuse allegation involving a resident who was not cognitively impaired and relied on staff for activities of daily living. The incident involved a staff member allegedly slapping the resident's hand, taking the call bell out of reach, and leaving the room. The facility's investigation did not verify with the nursing staff who brought medications to the resident that morning, nor did it include interviews with all relevant staff members who may have had contact with the resident during the alleged event. The investigation was incomplete as it did not include interviews with the nurse assigned to the resident on the day of the incident, nor did it ask specific questions about the events reported. The Nursing Home Administrator acknowledged that the interviews were conducted by a Unit Manager who was unavailable for further clarification. The lack of a comprehensive investigation was evident as there was no additional information provided by the end of the survey.
Failure to Administer Ordered Medication
Penalty
Summary
The facility failed to administer a physician-ordered medication to a resident, identified as Resident #22, who was admitted with a history of sepsis, urinary tract infection (UTI), and metabolic encephalopathy. The resident was supposed to receive an intramuscular (IM) injection of Rocephin, an antibiotic, on a specific date as per the physician's order. However, the medication was not administered as required, and there was no documentation on the Medication Administration Record (MAR) to indicate that the medication was given. The Licensed Practical Nurse (LPN) involved initially claimed to have administered the medication but later admitted to the Director of Nursing (DON) that the medication was not given. The facility's Pyxis system, which tracks medication dispensing, showed no record of the Rocephin being removed for administration to the resident on the specified date. This discrepancy was confirmed by the facility's pharmacist, who noted that there were no charges for the medication, indicating it was not dispensed. Interviews with the Nurse Practitioner and the Physician confirmed that the resident was intended to receive the IM Rocephin as ordered. Despite the failure to administer the IM dose, the resident later received six days of intravenous (IV) Rocephin through a peripherally inserted central catheter (PICC) line. The Physician noted that the resident's prognosis was poor, and the omission of one dose would not have significantly impacted the resident's condition. The facility's Administrator stated that all medications ordered by a physician or nurse practitioner are expected to be administered as ordered.
Failure to Enforce Mask-Wearing During COVID-19 Outbreak
Penalty
Summary
The facility failed to ensure that all staff were wearing masks during a COVID-19 outbreak, as observed on one of the four floors. Upon entry to the facility, it was reported that masks were required due to the outbreak. However, on the transitional care unit, a Geriatric Nursing Assistant (GNA) was observed sitting in an open dining area without a mask. During a 15-minute interview, the GNA did not put on a mask. Another GNA joined the table, removed her mask, and then put it back on only to remove it again upon returning to the area. Additionally, a Housekeeping Aid (HA) was observed sitting in a common area without a mask. The Director of Nursing (DON) was present during this observation and questioned the HA, who indicated she had the mask with her but was not wearing it. The DON confirmed that all staff were expected to wear masks in resident care areas, but this was not adhered to during the observations. The Operations Manager stated that staff had been educated about mask-wearing requirements during the outbreak, but the observations indicated non-compliance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Gaithersburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Montgomery Village Care Center | 1.5 mi | ★★★★★ | 0 | 0 |
| Ingleside At King Farm | 2.7 mi | ★★★★★ | 13 | 0 |
| Shady Grove Nursing And Rehabilitation Center | 3.2 mi | ★★★★★ | 4 | 0 |
| Collingswood Rehabilitation And Healthcare Center | 4.3 mi | ★★★★★ | 18 | 0 |
| Sterling Care Rockville Nursing | 4.7 mi | ★★★★★ | 8 | 0 |
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