Frederick Villa Healthcare

Inspectors wroteBased on resident interviews, record review, reviews of other pertinent documentation, and staff interviews, it was determined that the facility failed to treat a resident who complained of severe pain resulting in harm to the resident. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of a clinical record and all pertinent documentation, and staff interviews, it was determined that the facility failed to obtain the staff needed to escort a resident to an outside physician's office visit. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of clinical records and all pertinent administrative records, and staff interview, it was determined that the facility staff failed to promptly notify the ordering physician or clinical practitioner of a laboratory result. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of a clinical record and all pertinent documentation, and staff interview, it was determined that the facility failed to follow a physician's order to obtain a timely infectious disease and urology consult. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on complaint, reviews of a clinical record and all pertinent documents, and interviews with facility staff, it was determined that the nursing staff failed to 1) follow the physician ordered parameters when documenting a resident's lung sounds every shift, and 2) obtain a resident's pacemaker check every shift for proper functioning. This was evident for 1 (Resident #1) of 6 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure the baseline care plan reflected the resident's current medications at the time of admission. This was evident for 1 (Resident #10) out of 10 residents reviewed during the complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined that the facility staff failed to develop a comprehensive person-centered care plan for a resident with extensive pressure ulcers. This was evident for 1 (Resident #5) of 2 residents reviewed for pressure ulcers during a complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to administer an antibiotic for an infection as prescribed in the discharge instructions from the hospital. This was evident for 1 (Resident #6) of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on record review and staff interview, it was determined that the facility failed to ensure residents remained free from significant medication errors. This was evident for 1 (Resident #10) out of 10 residents reviewed during the complaint survey.

Inspectors wroteBased on medical record review, complaint review, and interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 2 (Resident #5, #4) of 10 residents reviewed during a complaint survey.

Inspectors wroteBased on facility documentation and an interview, it was determined that the facility failed to have a qualified Infection Preventionist (IP). This failure has the potential to affect all residents in the facility.

Inspectors wroteBased on review of complaint 337259 and the facility's pest problem logs and interview with facility staff, it was determined that the facility failed to maintain an effective pest control program. This deficient practice had the potential to impact all residents.

Inspectors wroteBased on review of facility reported incidents (Intake #2578127, # 337212 and #337236), record review, and interview, it was determined that the facility failed to ensure that all alleged resident violations were reported in a timely manner, including: abuse, neglect, exploitation or mistreatment. This was evident for 6 (Resident #86, # 143, #71 #101, #2, and #140) of 76 Residents that were part of the survey sample.

Inspectors wroteBased on a review of resident medical records, and interviews with facility staff, it was determined that the facility failed to: 1) review and revise the resident's care plan as required, 2) hold or document interdisciplinary team care plan meetings at the time of quarterly revisions, and 3) to ensure participation in the care planning process by the required interdisciplinary team (IDT) members. This was evident for 7 (Resident #10, #74, #8, #13, #15, #68, and #130) of 34 residents reviewed during the investigation phase of the facility's recertification/complaint survey.

Inspectors wroteBased on observation and interviews with residents and facility staff, it was determined that the facility failed to ensure that the environment of resident care was maintained in a manner that minimized the potential spread of infection. This was evidenced by: 1) an isolation sign for a COVID-19 positive resident was not posted, 2) antiviral medication for the COVID-19 positive resident was not administered in a timely manner, and 3) staff in the laundry failed to use standard precautions when they handled contaminated linens. This was evident for two (Resident #46 and #67) of two residents reviewed for COVID-19 positive and was also observed in the laundry room during the survey.

Inspectors wroteBased on observation and staff interview, it was determined the facility staff failed to treat a resident in a dignified manner by leaving a urinal that contained urine hanging on the bedrail during meal time. This was evident for 1 (Resident #49) of 74 residents reviewed during a recertification / complaint survey.

Inspectors wroteBased on a review of medical records and interviews, it was determined that facility staff failed to 1) ensure that two physicians' certificates of incapacity were obtained and that Advance Directives were completed in accordance with the Health Care Decisions Act. This failure occurred before allowing resident representatives to make informed health care decisions on a resident's behalf. The Facility also failed to 2) provide written information to all residents concerning the right to formulate an Advanced Directive (AD). This was evident for 2 (Resident #8 and Resident #11) for 32 residents records reviewed for advance directives during the initial pool phase of the survey.

Inspectors wroteBased on complaint intake, record review and staff interviews, it was determined that the facility failed to 1) notify the Power of Attorney when a resident fell out of bed and 2) notify the physician of a missed medical appointment. This was evident for 1 (Resident #127) of 42 Intakes reviewed during a recertification/complaint survey.

Inspectors wroteBased on surveyor observation and interviews with residents and facility staff, it was determined that the facility failed to maintain a safe, clean, comfortable and homelike environment. This was evident for 2 (Resident #15 and Resident #133) of 44 residents reviewed from the complaints and facility reported incidents investigated during the facility's recertification survey.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to provide documented evidence to support that each resident was free from unnecessary medication administration. This was evident for 1 (Resident #74) of 5 resident's assessed for unnecessary medications during the recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to accurately code a diagnosis in the Minimum Data Set (MDS). This was evident for 1 (Resident #15) of 8 resident reviewed for Antipsychotic medication ( a type of drug primarily used to treat symptoms of psychosis, such as hallucinations and delusions, by blocking dopamine in the central nervous system) use and related diagnosis reviewed during the recertification/complaint survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to ensure a baseline care plan, including a current list of medications, was provided to the resident and/or resident representative (RP) and documented in the medical record. This was evident for 2 (Resident #126 and #122) out of 36 residents reviewed during the investigation phase of the facility's recertification survey.

Inspectors wroteBased on review of medical records and interviews with facility staff, it was determined that the facility failed to provide the required level of assistance for a resident to perform their Activities of Daily Living. This was evident for 1 (Resident #122) out of 36 residents reviewed during the investigation phase of the facility's recertification survey.

Inspectors wroteBased on complaint incidents, record reviews, and staff interviews, it was determined that the facility failed to provide quality of care services to residents in their facility. This was evident for 2 (Residents #135 and #127) of 42 intakes reviewed during the recertification/complaint survey.

Inspectors wroteBased on record review and interviews it was determined the facility failed to:1) provide timely, consistent care and treatment for a resident with pressure ulcers, 2) ensure a wound consult was completed timely, 3) provide services to promote healing of pressure ulcers, and 4) have interventions on plan of care for pressure ulcers. This was evident for 2 Resident (Resident #126 and Resident #5) of 3 residents reviewed for Pressure Ulcers during the facility's recertification/complaint survey.

Inspectors wroteBased on record review, resident and staff interview, it was determined the facility failed to adequately assess urinary incontinence and implement a care plan to restore continence to the fullest extent possible. This was evident for 1 (Resident #107) of 1 residents reviewed for Bladder and Bowel Incontinence during the recertification/complaint survey.

Inspectors wroteBased on record review, resident interview, review of complaint intake #337241 and staff interviews, it was determined that the facility failed to 1) monitor a resident for pain and schedule an appointment for pain management following hospital discharge, and 2) ensure that a resident was given pain medication consistent with professional standards of practice. This was evident for 3 (Resident #107, #127, and #68) out of 76 residents reviewed during the recertification/complaint survey.

Inspectors wroteBased on review of employee files and staff interview, it was determined that the facility failed to perform annual performance reviews for the Geriatric Nursing Assistants (GNA). This was identified for 3 (GNA #38, GNA#43, and GNA #44) of 5 GNAs reviewed during a recertification / complaint survey.

Inspectors wroteBased on medical record review and interview, it was determined the facility staff failed to ensure a resident was free from unnecessary medications. This was evident for 1 (Resident #49) of 74 residents reviewed during a recertification/complaint survey.

Inspectors wroteBased on observation and interview it was determined facility staff failed to safely store medications and dispose of expired medications and patient supplies. This was evident on 2 of 3 nursing units observed for Medication Storage and Labeling during a recertification survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to assist the resident in making appointments and arranging transportation to and from the dental services locations. This was evident for 2 (Resident #5 and Resident #10) of 3 residents reviewed for dental services during the recertification/complaint survey.

Inspectors wroteBased on observation and interview with facility staff, it was determined the facility failed to ensure food items were stored under sanitary conditions. This deficient practices was observed in the dry storage area during the recertification/complaint survey.

Inspectors wroteBased on a record review and staff interviews, it was determined that the facility failed to collect all the necessary information for monitoring its antibiotic stewardship program. This was evident in the review of all seven months of antibiotic stewardship records during this recertification/complaint survey.

Inspectors wroteBased on a review of clinical records and staff interviews, the facility failed to offer a resident a pneumonia vaccine upon admission. This was evident for one resident (Resident #68) out of the five reviewed for immunizations during this recertification/complaint survey.

Inspectors wroteBased on medical record review and staff interview, it was determined the facility failed to 1) document providing education regarding the benefits, risks, and potential side effects of receiving the COVID-19 vaccine to residents, and 2) maintain documentation related to COVID-19 vaccination status for staff. This was evident for 1 (Resident #2) of 5 residents and two (Staff #36 and #38) of five staff reviewed during this recertification/complaint survey.

Inspectors wroteBased on a medical record review, facility investigation review, and staff interviews, it was determined that the facility failed to thoroughly investigate allegations of abuse in a timely manner. This was evident for 5 residents (Resident #86, #143, #71, #131 and #73) of 8 residents reviewed for abuse during this recertification/complaint survey. The findings Included: 1) On 08/19/2025 at 9:04 AM, during the initial screening phase of the survey, Resident #86 reported to the surveyor that “on the recent Sunday night shift (8/17/2025) a nurse was very mean to her during care and when the nurse’s attitude was brought to the nurse’s attention, she just left the room and never came back. When asked if the incident was reported to anyone, Resident #86 stated “no”. The resident’s roommate (Resident #143) confirmed that the nurse was rough with her during care. [...]

Inspectors wroteBased on record review, review of the facility investigation of intake #337244, review of facility policy on Conduct and Behavior, resident interview, and staff interview it was determined that the facility staff failed to ensure a resident was free of misappropriation of property. This was evident for 1 (Resident #104) out of 75 residents who were part of the survey sample.

Inspectors wroteBased on complaint intake # 337241, medical record review, and staff interview it was determined that the facility failed to ensure the resident's discharge papers were completed. This was evident for 1 Resident (#127) of 4 residents reviewed for discharge during a recertification / complaint survey.

Inspectors wroteBased on record review, a facility reported incident (Intake #2578127) and interviews, it was determined that the facility failed to maintain medical records on each resident that were complete and accurately documented. This was evident for 2 (Resident #74 and Resident # 127) out of 76 resident records reviewed during the survey process.

Inspectors wroteBased on reviews of a facility reported incident, reviews of administrative records, and staff interviews, it was determined that the facility failed to provide abuse education to geriatric nursing assistant (GNA) upon their hired date. This was evident for 1 (Staff #39) of 5 GNAs abuse education reviewed during a recertification/complaint survey.

Inspectors wroteBased on observation and interview it was determined that the facility staff failed to store and serve food according to professional standards. This deficient practice has the potential to affect the residents with meal service within the Candlelight Dining Room.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to provide a safe, comfortable homelike environment for the residents. This deficient practice has the potential to affect all the residents who reside in Unit #2 [NAME] Way.

Inspectors wroteBased on observations and interviews it was determined that the facility staff failed to maintain an effective pest control program as evidenced by numerous alive and dead bugs seen throughout the facility during the annual survey. This deficient practice was observed throughout the building on multiple units, hallways, bathrooms and resident rooms.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that the resident's call light was within reach to allow access to assistance when needed. This was found to be evident for 2 (Resident # 36 and # 48) of 102 residents observed during the facility's annual Medicare/Medicare survey.

Inspectors wroteBased on a review of pertinent documentation, medical records, observations, and staff interviews it was determined the facility failed to ensure that a Minimum Data Set (MDS) was completed accurately for a resident with urinary retention. This was found to be evident for 1 resident (Resident # 36) that was reviewed for catheters during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on medical record review and staff interview it was determined the facility failed to: 1.) consistently implement a care plan that addressed Resident (#52's) need for anticoagulant therapy; 2,) update a resident care plan to meet the needs of a Resident (#36) with urinary retention; and 3.) ensure residents had an interdisciplinary care plan meetings while residing in the facility (Residents #25, #43, #87). This was evident for 5 of 50 residents reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observation and interview it was determined that the facility staff failed to ensure nursing staff stayed awake during their tour of duty. This was evident for 2 of 3 units observed during the survey process.

Inspectors wroteBased on medical record review and interview, the facility staff failed to review provider notes for treatment accuracy. This was evident for 1 of 5 residents (Resident #1) reviewed for nutritional deficiencies.

Inspectors wroteBased on record review and interview with facility staff it was determined the facility failed to address and identify the use of a medication in a resident's plan of care. This was evident for one of five residents (Resident #52) reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview it was determined the facility staff failed to keep waste properly contained in dumpsters with lids that could be closed. This deficient practice involved two dumpsters on the facility property.

Inspectors wroteBased on medical records review and interview and it was determined that the facility failed to: 1.) document accurate and complete information on a resident's Fall Incident Report after the resident was found on the floor with difficulty breathing (Resident #52); and 2.) ensure that resident records were accurate and complete for a resident (Resident #36). This occurred in 2 of 50 residents reviewed during the facility's annual Medicare/Medicaid survey.

Inspectors wroteBased on observations and interviews with facility staff it was determined the facility failed to ensure that assignment boards and assignment sheets were completed for the current shift. This was found to be evident for 2 of 3 units observed during the facility's annual Medicare/Medicaid survey.

Inspectors wrote2. On 5/22/19 review of Resident #8's medical record revealed the resident had been receiving a diuretic medication daily since February 2019. Review of the MDS, with an assessment reference date of 5/1/19, revealed that it failed to assess the resident's use of a diuretic. On 5/22/19 at 11:27 AM surveyor reviewed the concern with the MDS Nurse #11 that the resident had orders for a diuretic since February 2019 and no documentation was found on the MDS assessment that a diuretic had been administered. On 5/22/19 at 11:44 AM MDS Nurse #11 confirmed that the MDS was incorrectly coded for the diuretic usage for this resident. 3. On 5/21/19 review of Resident #54's medical record revealed the resident had resided at the facility for several years and whose diagnosis includes quadriplegia (loss of use of all four limbs). [...]

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure that a copy of the resident's Maryland Medical Orders for Life Sustaining Treatment (MOLST) was accurate. This was found to be evident for 1 of 5 residents reviewed (Resident #45) in the investigative stage of the survey.

Inspectors wroteBased on medical record review and interview with the facility staff, it was determined that the facility failed to provide notification to residents that their Medicare coverage was ending. This was evident in 3 of 3 residents (Resident #80, #308 #42) reviewed during beneficiary protection task.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to maintain the physical environment of the facility in good repair as evidenced by multiple cracked and damaged floors. This was found to be evident in the hallways and the dining room and has the potential to affect all residents.

Inspectors wroteBased on the review of a facility reported incident (FRI), review of pertinent records and interview with facility staff, it was determined that staff failed to report an allegation of abuse. This was found to be true for 2 out of 2 residents (Resident #108 and #39) reviewed for an allegation of abuse in the investigative stage of the survey.

Inspectors wroteBased on medical record review, and interview with facility staff it was determined that the facility failed to develop person-centered individualized comprehensive care plan as evidenced by: 1) failure to develop a care plan to address a resident activities, 2) failure to develop a care plan to address the resident pain, 3) failure to develop a care plan to address the resident diagnosis and 4) failure to follow the care plan to administer pain medication. This was found to be true for 3 out of 30 residents (Resident #2, #44 and #36) reviewed during the investigation stage of the survey.

Inspectors wroteBased on observations, interviews of facility staff and medical record review it was determined the facility failed to update a resident care plan to include an open area that was being treated. This was found to be evident for 1 resident (Resident #36) reviewed for non pressure areas during the facility's annual survey.

Inspectors wroteBased on observations of residents, review of medical l records and staff interview it was determined that the facility staff failed to ensure residents are provided with activities that meet the resident's needs based on their assessment. This was evident for 1 out of 5 residents (Resident #2) reviewed for activity during the investigation stage of the survey.

Inspectors wroteBased on medical record review, observation and interview with staff it was determined that the facility failed to ensure resident's received treatment and care in accordance with professional standards of practice as evidenced by: 1) failure to follow physician orders regarding frequency of primary care visits (Resident #8); 2) failure to complete ordered therapy evaluations and failure to ensure orders for wound treatments were documented in the medical record (Resident #54); 3) failure to follow a physician order related to a splint (Resident #69); [...]

Inspectors wroteBased on medical record review and interviews it was determined that the facility failed ensure restorative nursing services were provided in accordance with residents' care plans. This was found to be evident for 2 out of the 4 residents (Resident #47 and Resident #76) reviewed for activities of daily living but has the potential to affect all residents with restorative nursing needs.

Inspectors wroteBased on medical record review and interviews with the residents and facility staff, it was determined the facility failed to: 1) follow-up to ensure that the resident pain was managed appropriately; 2) administer medication in accordance to the physician orders and resident needs; 3) to assess a resident's pain. This was found to be true for 3 out of 5 residents (Resident #36, #6 and #90) reviewed for pain management during the investigative stage of the survey.

Inspectors wroteBased on interview with residents, observation and review of resident council meeting minutes it was determined that the facility failed to: 1) put in a system to effectively answer and respond to residents needs timely when the call light is turned on and 2) have sufficient staffing to provide restorative nursing services in accordance with residents' care plans. This was found to be evident for 1 out of the 4 residents (Resident #47) reviewed for activities of daily living but has the potential to affect any resident with a care plan for restorative nursing services and all residents who use call lights.

Inspectors wroteBased on review of facility policy and interview with staff it was determined that the facility failed to ensure the required components were included in the medication regimen review policy. This was found to be evident during the review of unnecessary medications and has the potential to affect all residents.

Inspectors wroteBased on medical record review, interview with residents and facility staff it was determined that the facility failed to: 1) monitor a resident's blood pressure as ordered by the physician and 2) prevent duplicate medication therapy. This was evident in the review of 2 of 5 residents (Resident #45 and Resident #60) reviewed during the investigative stage of the survey.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure medications were kept in a secured location as evidenced by the observation of various medications awaiting pick up by pharmacy kept at the open nursing station. This was found to be evident on 1 of the 3 nursing units.

Inspectors wroteBased on the review of a facility reported incident (FRI) and review of pertinent facility documentation and observation it was determined that the facility provided a resident (Resident #69) with a meal containing items on his/her allergy list. This was evident during the investigative portion of the survey.

Inspectors wroteBased on medical record review and interview with staff it was determined that the facility failed to ensure medical records were maintained in accordance with accepted professional standards as evidenced by failure to: 1) ensure staff only document medications that they actually administered; 2) document when medication was administered and 3) failed to ensure that a resident pain assessment and evaluation of the pain was documented in the resident medical record. This was found to be evident for 4 out of 30 residents (Resident #8, #47, #36 and #6) reviewed during the survey.