Westgate Hills Rehab & Healthcare Ctr
WESTGATE HILLS REHAB & HEALTHCARE CTR in BALTIMORE, MD — inspection on December 31, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The surveyor asked the DON what type of treatment would be offered to a resident with moisture associated skin damage (MASD) and she explained that a barrier cream after incontinent care and watching the wound closely would be standard practice.
However, if the wound nurse practitioner assessed the wound, they may provide other wound care orders for us to follow.
The DON was notified of the following concerns: inconsistency with Resident #2 skin assessment documentation less than 24 hours after admission (the resident's admitting nurse documented: skin intact on10/2/2025; the facility's wound care nurse documented: pressure ulcer stage 3 on left buttock on 10/3/2025 and the NP documented MASD on 10/3/2025).
There was also no indication that the wound care treatment was initiated upon admission.
The resident wound care treatment was started on 10/12/2025, which potentially contributed to a decline in the resident skin integrity.
The DON stated that she will review resident's hospital records.
On 12/31/2025 at 3:53 pm, the DON stated that she reviewed the resident's hospital record which did not indicate that the resident had a wound upon discharge from the hospital.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
12/31/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Westgate Hills Rehab & Healthcare Ctr
10 North Rock Glen Road Baltimore, MD 21229
SUMMARY STATEMENT OF DEFICIENCIES
Based on a review of records and interviews, it was determined that the facility failed to assess or document residents' behaviors regarding mental illness.
This was evident for one resident (Resident #7) out of eight residents reviewed during this complaint survey.
The findings include: On 12/30/25 at 1:50 PM, the surveyor conducted a phone interview with the complainant for case #2659413.
During the interview, the complainant reported that they were not informed of Resident #7's worsening agitation, wandering, and/or behaviors, such as entering other residents' rooms and touching their belongings.
The complainant stated that when the resident was ready to be readmitted to the facility, management resisted, claiming that Resident #7 had worsening behavioral issues that resulted in the facility increasing its budget to address the problems.The surveyor reviewed Resident #7's medical records on 12/30/25 at 2:15 PM.
The review revealed that the resident had resided at this facility since October 2025 with a diagnosis of dementia with behavioral disturbance.
Additionally, the resident was prescribed medications (Risperidone, Divalproex, and Trazodone) for those diagnoses upon admission; however, there was no order/documentation for behavior monitoring.During a phone interview with the Psychiatric Nurse Practitioner (Staff #5) on 12/30/25 at 5:23 PM, she recalled Resident #7's condition as aggressive, including making false accusations and wandering.
The surveyor asked how Staff #5 became aware of the resident's condition.
She stated, It was a verbal report; there was no documentation that I referred to.In an interview with the Director of Nursing (DON) on 12/30/25 at 5:49 PM, she stated that Resident #7's behavioral issues were documented in the care plan and that behavior monitoring for every shift should have been documented in the Treatment Administration Record.
The surveyor reviewed Resident #7's medical records with the DON.
The DON verified that there was no assessment or documentation of the resident's behavior.
Facility ID: