Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Collingswood Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Staff failed to timely report injuries of unknown origin for two residents to state authorities. In one case, a family member informed a GNA about a contusion on a resident’s upper arm, but the GNA did not assess the resident and forgot to notify a nurse or other staff, and the injury was not brought to administration’s attention until the family later emailed the ADON, resulting in a multi-day delay in reporting to OHCQ. In the other case, nursing staff identified and treated a bruise on a resident’s thigh and informed the Dementia Unit Manager, who did not notify the DON or Administrator until several days later, causing a late Facility Reported Incident submission to OHCQ.
The facility failed to thoroughly investigate both an abuse allegation and an injury of unknown source. An alert, newly admitted resident with complex medical needs reported in writing being beaten during bath time on the second day of admission, but there was no documented resident interview, no interviews with other residents on the unit, incomplete staff interviews across all shifts, and no written statement from the nurse manager who received the allegation. In a separate case, a severely cognitively impaired, ventilator‑dependent resident exhibited pain with right arm movement, and an initial x‑ray suggested a wrist fracture later not confirmed at the hospital; however, the facility’s investigation only included statements from staff present at the time of the observed pain and one assisting GNA, with no interviews of staff from prior shifts or any residents regarding the injury of unknown source.
A resident who was his/her own decision maker received a notice of non-coverage with a planned discharge date and initially agreed to go home, with Social Services documenting plans for home health and transportation by taxi. After the resident’s family member told the Social Services assistant they wanted to appeal the discharge and believed the resident needed more time, the assistant informed staff that the resident would be staying and told the resident about the family’s wishes, but did not document this change in the discharge plan or the appeal in the medical record, resulting in an incomplete and inaccurate record.
Multiple wheelchairs were found to be unsanitary and in disrepair, including one used by a resident for an outside appointment that contained urine and fecal matter in the cushion. Several other wheelchairs had cracked, ripped, or missing armrests, with exposed foam and inadequate support. Housekeeping staff confirmed there was no prior cleaning or maintenance schedule for wheelchairs or their cushions.
Facility staff failed to accurately code MDS assessments for several residents, resulting in omissions and errors related to significant weight loss, falls, pressure ulcers, wounds, and the administration of medications such as hypoglycemics, antibiotics, anticoagulants, and opioids. These discrepancies were confirmed by MDS coordinators after review of medical records and medication administration records.
A resident with a leg amputation was not provided with their custom-made wheelchair during transport to a medical appointment, resulting in the use of other wheelchairs and repeated repositioning by staff. The facility lost the resident's specially fitted wheelchair on multiple occasions, and staff failed to follow up to ensure the resident had access to the necessary equipment, despite complaints from the resident's family and awareness among facility leadership.
Facility staff failed to promptly notify a physician after a resident with heart failure experienced a sudden and sustained drop in blood pressure, despite repeated attempts to reach the provider and ongoing monitoring. In a separate incident, another resident experienced a significant weight loss over three weeks, but there was no timely notification to the physician, dietician, or family, and the resident was not promptly assessed or discussed in risk meetings.
The facility did not report allegations of abuse, neglect, or injuries of unknown origin to the regulatory agency within the required 2-hour timeframe for three residents. Incidents included a non-verbal resident with a laceration, a resident with a dislocated shoulder and complex medical needs, and an allegation of physical abuse by a GNA. In each case, delays in internal notification and external reporting were confirmed.
Facility staff did not hold or document required quarterly care plan meetings for a resident with dementia, despite completing quarterly MDS assessments. Only one care plan meeting was documented, and there was no record of meetings or summaries for other required quarters, as confirmed by the DON and noted by the resident's representative.
A resident who required extensive two-person assistance for activities of daily living after hip surgery did not receive necessary turning, repositioning, or bowel and bladder care over several day shifts. Documentation showed that assigned GNAs did not perform these essential care tasks, and complaints included inadequate staffing and unanswered call bells.
Facility staff did not implement a consultant's recommendations for an appetite stimulant and protein supplement for a resident with anemia and thyrotoxicosis, and also failed to perform and document neurological assessments at required intervals after an unwitnessed fall for another resident, with inaccuracies in vital sign documentation as confirmed by the DON.
A resident with multiple medical conditions experienced a significant, unrecognized weight loss over a three-week period. Facility staff did not perform weekly weights as recommended, failed to promptly notify the physician or dietician of the weight loss, and delayed assessment and intervention, contrary to facility policy.
Failure to Timely Report Injuries of Unknown Origin to State Authorities
Penalty
Summary
Facility staff failed to timely report injuries of unknown origin for two residents to the State of Maryland's Office of Health Care Quality (OHCQ). For one resident, a family member noticed a contusion on the resident's right upper arm while visiting and reported this skin issue to the assigned Geriatric Nursing Assistant (GNA) at approximately 2:30 PM. The family member asked that the resident not be disturbed because the resident was asleep, and the GNA did not assess the resident at that time. The GNA then unintentionally failed to report the family’s concern or the potential injury to a nurse or any other staff member before leaving for the day. The facility did not become aware of the injury until the family member emailed the Assistant Director of Nursing (ADON) several days later, at which point the injury of unknown origin was reported to OHCQ, resulting in a four-day delay from when the family first identified and reported the potential injury to staff. In a separate incident, another resident was observed by nursing staff with a bruise to the right thigh that was treated and documented as an injury of unknown origin. Nursing staff reported this injury to the Dementia Unit Manager, but the Dementia Unit Manager did not notify the Director of Nursing (DON) or the Administrator on the date the injury was discovered. Administration only became aware of the injury several days later when the Dementia Unit Manager reviewed the nursing documentation and recognized that the injury met criteria for an injury of unknown origin. The injury was then reported to the DON and subsequently to OHCQ, but this delay caused the facility to report the injury to the state agency late. Both incidents were confirmed through staff interviews and review of the facility-reported incident investigations.
Failure to Thoroughly Investigate Abuse Allegation and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of abuse for one resident. An alert and oriented resident with multiple diagnoses and complex medical needs was admitted following an acute hospitalization and later provided the Unit Manager with a handwritten note alleging that on the second day of admission the resident was “beaten up during bath time.” The note did not identify staff or the shift involved. Review of the investigation showed no documentation that the resident was interviewed about the allegation after staff became aware of it. The investigation file also contained an undated typed statement indicating that when social services went to visit the resident about an incident, the resident declined to talk and declined to write a statement, but the document did not identify the author, the social services staff involved, or the specific incident referenced. Further review of the abuse investigation revealed that no interviews were documented with other residents on the unit, despite the allegation of abuse. Instead, statements were obtained from resident representatives for three other residents who were documented as cognitively impaired and not interviewable, with no documentation explaining why residents themselves were not interviewed. Staff interview statements were only obtained from the nurse and GNA on the 7 AM–3 PM shift and the nurse and GNA on the 3 PM–11 PM shift for the date of the alleged incident. There was no documentation of interviews with the nurse and GNA assigned to the resident on the 11 PM–7 AM shift, and no written statement from the Unit Manager who originally received the handwritten abuse allegation from the resident. The deficiency also includes the facility’s failure to thoroughly investigate an injury of unknown source for another resident. This resident, admitted with multiple diagnoses, severe cognitive impairment, and ventilator dependence, displayed a facial grimace when staff moved the right arm during incontinence care, leading to an x-ray that suggested a possible hairline fracture of the right wrist, followed by a later hospital x-ray that showed no fracture. The facility’s investigation contained only three employee statements: from the RN and GNA providing care at the time of the observed grimace, and from a GNA who was not assigned to the resident but assisted with care that day. There was no documentation that staff from preceding shifts or days were interviewed, and no documentation that any residents were interviewed in response to the injury of unknown source.
Failure to Accurately Document Change in Discharge Plan and Appeal
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record for a resident in accordance with accepted professional standards. Facility investigative documentation for a facility-reported incident showed that a resident, who was his/her own decision maker, left the facility in the early morning hours without informing staff and later returned home safely. Review of records also showed that the resident had been given a notice of non-coverage indicating the last covered day of the stay and the right to appeal, and the resident signed this notice. Further review of the resident’s medical record revealed a Social Services progress note documenting that the Social Services Assistant received the last covered day notice and that the resident was ready to go home and planned to discharge earlier than originally indicated, with home health to be set up and the resident planning to go home by taxi. In a subsequent interview, the Social Services Assistant stated that after providing the notice, she contacted a family member involved in the resident’s care, who expressed a desire to appeal the discharge and felt the resident needed more time. The Social Services Assistant reported that she informed staff there would be an appeal and that the resident would be staying, and she later told the resident about the family member’s wish for the resident to remain. She confirmed that she did not document this updated discharge plan and appeal information in the resident’s medical record, resulting in an incomplete and inaccurate record for the resident.
Failure to Maintain Sanitary and Safe Wheelchairs
Penalty
Summary
The facility failed to maintain wheelchairs in a sanitary, comfortable, and well-maintained condition, as evidenced by observations and interviews during a complaint survey. One resident attended a medical appointment in a wheelchair with a cushion that was found to contain urine and fecal matter, emitting a strong odor that had been a source of complaints for months. Upon inspection, the gel pad and pillow cover were visibly soiled, and the family, as well as medical staff at the appointment, were disturbed by the condition. Housekeeping staff confirmed that prior to this incident, there was no established schedule for cleaning or maintaining wheelchairs or their cushions, and the wheelchair in question appeared to have never been cleaned. Further observations revealed multiple wheelchairs across two nursing units in disrepair, including cracked and ripped vinyl on armrests, missing armrests, and exposed foam. Several residents were observed using these damaged wheelchairs, which lacked proper padding and support. The Nursing Home Administrator was made aware of these issues by both staff and family members, confirming the lack of a maintenance process for wheelchairs prior to the incident.
Inaccurate MDS Coding for Resident Assessments
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, as evidenced by discrepancies between medical records and MDS documentation. For several residents, significant clinical events and treatments were not properly recorded in the MDS. One resident experienced a substantial weight loss and a fall, neither of which were accurately reflected in the corresponding MDS sections. Additionally, the administration of hypoglycemic medications and insulin was omitted from the MDS, while an opioid was incorrectly documented as administered when it was not present in the medication administration record. Another resident was admitted with bilateral heel wounds and received ongoing wound care and antibiotics, but the MDS failed to capture the presence of pressure ulcers, venous ulcers, and related treatments. The same resident's MDS also did not reflect the administration of multiple medications, including insulin, diuretics, opioids, antidepressants, antibiotics, and anticoagulants, despite clear documentation in the medical and treatment records. Similar omissions were found for other residents, where falls, pressure ulcers, and the use of specific medications such as antibiotics and anticoagulants were not accurately coded in the MDS, even though these events and treatments were documented elsewhere in the medical record. In one case, a resident's MDS assessment incorrectly indicated the presence of a pressure ulcer that had already healed, and failed to document the use of antiplatelet, hypoglycemic, and antipsychotic medications that were administered during the assessment period. Interviews with MDS coordinators confirmed the presence of these errors across multiple assessments, indicating a pattern of inaccurate MDS coding that did not align with the residents' actual clinical status and care provided.
Failure to Provide Resident with Custom-Made Wheelchair for Transport
Penalty
Summary
The facility failed to ensure that a custom-made wheelchair was available and provided for a resident with a leg amputation during transport to a medical appointment. Staff statements and interviews revealed that the resident, who typically used a geri chair or remained in bed, was transferred to a standard wheelchair for an appointment, during which the resident began sliding out of the chair. Multiple staff members intervened to reposition the resident and eventually transferred the resident to a high-back wheelchair with a pillow for support. The resident did not report pain or injury during the incident. Further investigation revealed that the resident's custom-made wheelchair, provided by the VA and specifically fitted to accommodate the resident's needs following a leg amputation, had been lost by the facility on more than one occasion. The resident's daughter reported that the resident was repeatedly placed in other residents' wheelchairs for appointments, and that complaints about the missing wheelchair had been made to various staff and administrators. The facility's NHA confirmed that the custom wheelchair could not be located and acknowledged that there was no follow-up by staff to ensure the resident had access to the appropriate equipment.
Failure to Timely Notify Physician and Family of Change in Condition and Significant Weight Loss
Penalty
Summary
Facility staff failed to notify a resident's physician in a timely manner following a significant change in condition. One resident, admitted with heart failure, experienced a sudden drop in blood pressure. Nursing notes documented that the resident's blood pressure fell to 70/54 and continued to decline over several hours. Despite repeated attempts to page the provider, there was no response, and the physician was not notified promptly. The family was present and refused hospital transfer, but the facility did not escalate the situation to the Medical Director as expected when the primary physician could not be reached. In another case, a resident experienced a significant weight loss of 25.8 lbs (20%) over three weeks. The medical record did not show timely notification to the physician, dietician, or family when the weight loss was identified. The dietician did not assess the resident until 11 days after the weight loss was documented, and the resident was not evaluated in weekly risk meetings until 13 days later. Facility policy required prompt notification of significant changes in condition, but this was not followed in these instances.
Failure to Timely Report Allegations of Abuse and Injuries
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injury of unknown origin to the regulatory agency, the Office of Health Care Quality (OHCQ), within the required 2-hour timeframe for three residents. In one case, a non-verbal, cognitively impaired resident was found with a laceration to the right thumb, but the incident was not documented or reported by the LPN on duty, and facility administration only became aware the following day. The self-report to OHCQ was sent more than 24 hours after the injury was discovered. In another instance, a resident with multiple complex medical conditions, including tracheostomy, G-tube, diabetes, hemiplegia, and ventilator dependence, was found to have a dislocated shoulder. The injury was confirmed, but the report to OHCQ was not made until the following day, exceeding the 2-hour reporting requirement. A third incident involved an allegation of physical abuse by a GNA, reported by a resident's spouse. The DON was not notified until the next morning, and the initial report to OHCQ was sent several hours after the required timeframe. Documentation from staff revealed inconsistencies in awareness and reporting of the alleged abuse. In all three cases, the DON confirmed the findings of late reporting during interviews, although the DON was not employed at the facility at the time of the incidents.
Failure to Hold and Document Required Quarterly Care Plan Meetings
Penalty
Summary
Facility staff failed to conduct quarterly care plan meetings for a resident diagnosed with dementia, as required following comprehensive and quarterly MDS assessments. The medical record review showed that while quarterly MDS assessments were completed, there was only documentation of a care plan meeting in April and a scheduled meeting in September, with no evidence of meetings in January and July. Additionally, there was no documentation summarizing or detailing what was discussed during the April and September care plan meetings. The resident's representative expressed concerns about the facility's lack of communication. The Director of Nursing confirmed that the required quarterly care plan meetings were not held for the resident in January and July, and that documentation of the content of the meetings that did occur was missing from the medical record.
Failure to Provide Required ADL Assistance and Repositioning
Penalty
Summary
A deficiency was identified when a resident, admitted for rehabilitation following surgery for a periprosthetic hip fracture and requiring extensive assistance with two-person support for transfers, bed mobility, dressing, toileting, and general hygiene, did not receive necessary care on multiple day shifts. Documentation review revealed that the assigned geriatric nursing assistant (GNA) failed to perform required turning, repositioning, and bowel and bladder care for the resident over three consecutive days. Additionally, complaints were made regarding inadequate staffing, lack of resident changing, turning, repositioning, and unanswered call bells. These findings were based on direct review of the resident's medical record and GNA documentation.
Failure to Follow Consultant Recommendations and Neuro Check Protocols
Penalty
Summary
Facility staff failed to provide care in accordance with consultant recommendations for a resident admitted with anemia and thyrotoxicosis. The resident was evaluated by a consultant who recommended starting an appetite stimulant and a prosource protein supplement due to poor appetite and low albumin levels. Despite these recommendations, the staff did not initiate either intervention before the resident was discharged from the facility. The Director of Nursing confirmed that these recommendations were not addressed. Additionally, staff did not properly perform and document neurological assessments following an unwitnessed fall for another resident. According to facility policy, neuro checks should be completed at specific intervals after such an event. However, the medical record showed that neuro checks were not performed or documented at the required times, and some entries included inaccurate or reused vital signs. The Director of Nursing confirmed that neuro checks were completed at incorrect intervals and with inaccuracies.
Failure to Recognize and Respond to Significant Resident Weight Loss
Penalty
Summary
Facility staff failed to recognize and respond to significant weight loss in a resident admitted for comprehensive rehabilitation with multiple diagnoses, including cerebral infarction, hypertension, type 2 diabetes with hyperglycemia, and a sacral wound. Upon admission, the resident's weight was documented as 128 lbs, a notable decrease from the ideal body weight of 154 lbs. Despite a dietician's recommendation for weekly weights and monitoring due to malnutrition risk, weekly weights were not performed after admission. The next recorded weight, taken three weeks later, showed a further drop to 102.2 lbs, representing a 20% loss. There was no evidence that the physician, dietician, or family were notified of this significant weight loss as required by facility policy. Additionally, the dietician did not assess the resident until 11 days after the documented weight loss, and the resident was not discussed in weekly risk meetings until 13 days after the weight loss was identified. The facility's policy required immediate notification of the dietician in writing for significant weight changes, but this was not followed. Interviews with the physician confirmed the expectation for prompt notification in such cases, which did not occur.
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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 Rockville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sterling Care Rockville Nursing | 0.6 mi | — | 8 | 0 |
| The Village At Rockville | 1.2 mi | — | 3 | 0 |
| Shady Grove Nursing And Rehabilitation Center | 1.3 mi | — | 3 | 0 |
| Potomac Valley Rehabilitation And Healthcare | 1.4 mi | — | 3 | 0 |
| Ingleside At King Farm | 1.6 mi | — | 13 | 0 |
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