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
Facility staff did not ensure that 2nd floor residents who could not use stairs were able to receive visitors when the only elevator was out of service for an extended period. Complaints indicated that some family members, who were themselves unable to ambulate stairs, could not visit their relatives on the 2nd floor during this time. The emergency plan directed non-ambulatory 2nd floor residents to remain on that floor unless there was an emergency and did not address how visitation would be maintained when the elevator was inoperable. The Administrator reported that visitors could use the stairs and that an emergency chair system could be used to move residents, but also stated that the chair system was not used for visitation and was unaware of any complaints, despite two having been filed.
Facility staff did not complete required quarterly smoking safety assessments for several residents identified as smokers, including some who had not been reassessed for many months and one who had never been assessed during their stay. This issue was discovered during a complaint survey after the facility’s only elevator was out of service for an extended period, affecting a group of residents on an upper floor who needed to reach a designated smoking area on a lower floor. Review of records and staff interviews, including with the DON and a unit manager, confirmed that the facility’s own practice of quarterly smoking safety assessments for smokers was not followed for half of the affected residents.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
Staff failed to conduct complete investigations into two residents’ abuse allegations. In one case, a resident reported that an employee poked their face and made an obscene gesture, but the investigation lacked a statement from the corporate representative who was first notified of the allegation. In another case, a resident reported that someone in blue clothing put a hand by their face and over their mouth, with a specific GNA identified as the alleged perpetrator; however, the investigation did not include statements from two GNAs who were on duty on the unit at the time of the alleged incident, despite leadership having the opportunity to ensure all relevant documents were present.
Staff failed to create person-centered care plans for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility issues, the care plan did not address the resident’s refusal to use a Hoyer lift and preference for pivot transfers, despite therapy prohibiting pivot transfers and staff awareness of the resident’s resistance. For the resident on peritoneal dialysis, the care plan did not specify that the treatment was peritoneal dialysis, nor did it include the treatment schedule or cycle time frames; an LPN Unit Manager acknowledged using a generalized renal care plan without incorporating the specific dialysis prescription.
A resident’s medical record lacked documentation confirming that scheduled showers or bed baths were provided on multiple dates, and there was also no record of any refusals of care on those days. The DON and an LPN unit manager reported that showers were scheduled on specific shifts and that completed showers and refusals should be documented on shower/skin sheets and in the care plan, but the surveyor found gaps where no such entries existed. This resulted in incomplete ADL documentation and failure to maintain medical records according to accepted professional standards.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Failure to Ensure Visitation Rights During Elevator Outage
Penalty
Summary
Facility staff failed to ensure that residents residing on the 2nd floor who could not safely ambulate using stairs were able to exercise their right to have visitors when the facility’s only elevator malfunctioned. Complaint reviews showed that family members were unable to visit their relatives on the 2nd floor when the elevator was inoperative, and these family members themselves were unable to use the stairs. An incident report documented that the facility’s only elevator was malfunctioning for an extended period, from 3/28/26 to 4/23/26. During this time, residents who could not use the stairs remained on the 2nd floor, and some of their family members could not access them due to the lack of elevator service. Review of the facility’s emergency plan revealed that it instructed that 2nd floor residents who could not safely use the stairs should remain on the 2nd floor unless there was an emergency, and it did not include any provisions for maintaining visitation when the elevator was inoperable. In an interview, the Administrator stated that visitors could use the stairs to visit 2nd floor residents and that residents could be transported using an emergency chair system to meet visitors who could not use the stairs. However, the Administrator acknowledged that the emergency chair system was not used for visitation purposes during the elevator outage and reported being unaware of any complaints about the inoperative elevator, despite two complaints having been received by OHCQ. No additional documentation was provided to show a plan to support visitation for 2nd floor residents during the elevator malfunction.
Failure to Complete Required Quarterly Smoking Safety Assessments
Penalty
Summary
Facility staff failed to update smoking safety assessments at least once every three months for multiple residents identified as smokers. During a complaint survey focused on smoking safety, surveyors reviewed an incident involving the facility’s only elevator being inoperative for nearly a month, which affected residents who lived on the 2nd floor and needed to access the 1st-floor smoking area. The facility’s investigation identified a group of 10 residents on the 2nd floor who smoked and required additional accommodations to safely ambulate to the designated smoking area. Review of these residents’ medical records showed that 5 of the 10 did not receive quarterly smoking safety assessments as required by the facility’s practice. Specifically, four residents had not received a smoking assessment since May 2025, and one resident had no documented smoking assessment at any time during their stay. During interviews, the Unit Manager stated that residents identified as smokers are to be assessed quarterly for smoking safety. When the surveyor pointed out the missing assessments, the DON reviewed the records and confirmed that these residents had not received the required quarterly smoking assessments. This lack of timely reassessment occurred in the context of an extended elevator outage that necessitated special consideration for safe smoking access for residents residing on the 2nd floor.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Incomplete Investigations of Resident Abuse Allegations
Penalty
Summary
Facility staff failed to complete thorough investigations of two separate resident allegations that were reported to the state agency. For the first incident, a resident alleged that on a specific date and time an employee poked two fingers into their face and showed them their middle finger. The five-day follow-up documented the allegation, but the investigation file did not clearly identify who was the first point of contact for the report. During interview, the Administrator stated that a corporate representative was initially made aware of the alleged incident, but there was no statement from this corporate representative included in the investigation file. The Administrator described their usual investigation process as interviewing involved parties, identifying and interviewing witnesses, reviewing staffing for the date of the alleged incident, and interviewing the resident’s roommate and other nearby residents if there were no direct witnesses. In the second incident, a resident reported that during a specific shift someone wearing blue put a hand by their face and over their mouth, and a particular GNA was identified as the alleged perpetrator. Review of the staffing sheet for the time of the alleged incident showed that two GNAs were working on the unit where the incident was reported to have occurred. However, the investigation file contained no statements or interviews from these two GNAs. Prior to the surveyor’s review of the investigation, the DON and a regional nurse were given the opportunity to review the investigation to ensure all necessary documents were available, yet the statements from the two GNAs remained absent. These omissions demonstrated that the facility did not conduct complete investigations into the reported allegations.
Failure to Develop Person-Centered Care Plans for Mobility and Peritoneal Dialysis Needs
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans that addressed all identified needs for two residents, one with mobility limitations and one receiving peritoneal dialysis. For the resident with mobility limitations, the care plan included interventions for resistance to care and adjustment issues, but did not address the resident’s specific resistance to use of a Hoyer lift and the resident’s insistence on pivot transfers from bed to wheelchair. The Unit Manager confirmed that the resident was resistant to care, did not like the Hoyer lift, and preferred pivot transfers, but also stated that physical therapy had prohibited pivot transfers. Despite this known conflict between the resident’s preferences and therapy restrictions, the care plan lacked individualized interventions related to the resident’s resistance to the Hoyer lift and continued request for pivot transfers. For the resident receiving peritoneal dialysis, review of the electronic health record showed an order for peritoneal dialysis, but the resident’s care plans did not include a person-centered care plan specific to this treatment. The existing dialysis care plan did not specify the type of dialysis treatment being provided, did not document when the resident was scheduled to receive the treatment, and did not include time frames for the dialysis cycles. During an interview, the LPN Unit Manager stated that they do not place the dialysis prescription details into the care plan and instead use a generalized renal care plan by selecting standard items, confirming that the care plan was not individualized to the resident’s ordered peritoneal dialysis regimen.
Failure to Document Resident Showers and Refusals
Penalty
Summary
Facility staff failed to maintain complete and accurate documentation of bathing care for a resident, specifically regarding showers and refusals of showers. During a complaint survey, the surveyor requested verification that Resident #5 was receiving scheduled showers. The DON stated that the resident was scheduled for showers on the 3 pm–11 pm shift on Tuesdays and Fridays, and provided shower sheets for several dates in October and early November. However, there was no documentation to verify that the resident received a shower or bed bath on 10/17/25, 10/21/25, and 10/24/25. The DON explained that when a resident receives a shower it is documented on a skin sheet, and that refusals of showers should be documented both in the plan of care and on the shower sheet. Despite this, the surveyor did not receive any documentation indicating that the resident either received bathing care or refused showers on the missing dates. This lack of documentation showed that the facility did not safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards, as there was no record confirming whether the resident’s scheduled showers or refusals occurred on the identified dates.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
