Resident #7 had lived at the Baltimore facility since October 2025 with a diagnosis of dementia with behavioral disturbance. Staff prescribed Risperidone, Divalproex, and Trazodone for the condition upon admission. But federal inspectors found no documentation of behavior monitoring anywhere in the medical records.
The family wasn't informed about the resident's worsening agitation, wandering, or habit of entering other residents' rooms and touching their belongings, according to a complaint filed December 30. When the resident was ready for readmission after a hospital stay, facility management resisted.
They claimed the resident's behavioral issues had forced them to increase their budget to address the problems.
The psychiatric nurse practitioner treating the resident described the patient's condition as aggressive during a phone interview with inspectors. The resident made false accusations and wandered throughout the facility, she said.
When inspectors asked how she became aware of these behaviors, her answer revealed the scope of the documentation failure.
"It was a verbal report," she told inspectors. "There was no documentation that I referred to."
The Director of Nursing initially told inspectors that the resident's behavioral issues were documented in the care plan. She said behavior monitoring for every shift should have been recorded in the Treatment Administration Record.
But when inspectors reviewed the medical records with her present, she verified there was no assessment or documentation of the resident's behavior.
The facility had been prescribing powerful psychiatric medications to control behaviors they weren't systematically tracking or recording. Risperidone is an antipsychotic typically used for severe behavioral symptoms in dementia patients. Divalproex is a mood stabilizer. Trazodone is commonly prescribed for agitation and sleep problems.
Without proper documentation, there was no way to determine if the medications were working, if behaviors were escalating, or if the resident needed different interventions.
The psychiatric nurse practitioner was making treatment decisions based entirely on verbal reports from staff. No written behavior logs. No systematic tracking of incidents. No formal assessments of the resident's mental state or response to treatment.
The family's complaint suggested they had been kept in the dark about the severity of their loved one's condition. They weren't notified about the wandering episodes or the resident entering other patients' rooms. They learned about the behavioral issues only when the facility pushed back against readmission, citing budget concerns.
Federal regulations require nursing homes to provide necessary behavioral health care and services. This includes proper assessment and documentation of residents' mental health conditions, especially for patients with dementia who may experience confusion, agitation, or other behavioral symptoms.
The facility's approach violated these requirements on multiple levels. They failed to create behavior monitoring orders despite knowing the resident had dementia with behavioral disturbance. They prescribed psychiatric medications without establishing a system to track their effectiveness. And they relied on informal verbal reports rather than documented assessments to guide treatment decisions.
The inspection, conducted as a complaint survey on December 31, 2025, found the facility's failures affected few residents but created potential for actual harm. Without proper documentation and monitoring, behavioral issues in dementia patients can escalate, potentially endangering both the affected resident and others in the facility.
Staff were medicating behaviors they weren't measuring, treating conditions they weren't formally assessing, and making clinical decisions without the documentation needed to ensure continuity of care.
The resident's family filed their complaint after discovering the facility's resistance to readmission was based on behavioral problems they had never been told about.
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.