Westgate Hills Rehab: Dementia Behavior Tracking Failures - MD
The resident, identified in inspection records only as Resident #7, had lived at Westgate Hills since October 2025 with a diagnosis of dementia with behavioral disturbance. Upon admission, doctors prescribed Risperidone, Divalproex, and Trazodone — a combination used to manage aggression, mood instability, and agitation. Despite those prescriptions, the facility created no order for behavior monitoring and kept no documentation of the behaviors those medications were meant to treat.
The family learned something was wrong not from the facility, but through their own efforts to get the resident back in.
A complainant, identified in the inspection report as the person who filed the case, told a federal surveyor during a phone interview on December 30 that the facility had never informed them of Resident #7's worsening agitation, wandering, or the incidents involving other residents' rooms. Then, when the family sought readmission for Resident #7, management pushed back. The facility cited the resident's worsening behavioral issues as a problem — issues serious enough, they said, that addressing them had increased the facility's operating budget. The family had heard nothing about any of this while it was happening.
The psychiatric nurse practitioner assigned to Resident #7's care told the surveyor she remembered the resident well. She described the behavior as aggressive, including wandering and making false accusations. When the surveyor asked how she had learned about the resident's condition, her answer was direct: "It was a verbal report; there was no documentation that I referred to."
A clinician managing psychiatric medications for a dementia patient was working from word of mouth.
The Director of Nursing told the surveyor that behavior monitoring for every shift should have been entered into the Treatment Administration Record, and that behavioral issues were documented in the care plan. Then the surveyor pulled up Resident #7's medical records and reviewed them with her in the room. The Director of Nursing confirmed that no assessment or documentation of the resident's behavior existed.
What the facility told the family, and what the records showed, pointed in opposite directions. Management described behavioral problems severe enough to justify blocking readmission. The medical record contained no evidence that those behaviors had ever been formally observed, measured, or reported.
Federal inspectors cited the failure as a violation with minimal harm or potential for actual harm, affecting few residents. One resident out of eight reviewed during the complaint survey had this problem documented. The inspection was conducted as a complaint survey, triggered by the case the family filed.
The practical consequences of the documentation gap ran in multiple directions. The psychiatric nurse practitioner adjusted care without written records to consult. Staff working overnight had no formal behavior log to reference from the prior shift. And the family, who had a right to be notified of significant changes in the resident's condition, received no notification at all — until the facility used those undocumented behaviors as grounds to resist letting the resident come back.
Dementia with behavioral disturbance is not a static diagnosis. Agitation, aggression, and wandering can escalate, plateau, or respond to medication adjustments, but only if someone is tracking what is happening shift by shift. At Westgate Hills, that tracking did not happen. The nurse practitioner said so. The Director of Nursing confirmed it while looking at the file.
The resident's family filed a complaint to find out what had been happening to their loved one inside the facility. What the inspection found was that the facility itself had not been keeping track.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westgate Hills Rehab & Healthcare Ctr from 2025-12-31 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 3, 2026 · Our methodology
WESTGATE HILLS REHAB & HEALTHCARE CTR in BALTIMORE, MD was cited for violations during a health inspection on December 31, 2025.
Upon admission, doctors prescribed Risperidone, Divalproex, and Trazodone — a combination used to manage aggression, mood instability, and agitation.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.