Frederick Villa Healthcare

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0550 during a standard health inspection conducted on 2025-08-28.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0578 during a standard health inspection conducted on 2025-08-28.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0580 during a standard health inspection conducted on 2025-08-28.

Category: Resident Rights Deficiencies

The facility was found deficient in the following area: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

sand ant sprays. The other invoice dated 8/18/25 showed bimonthly services for mice, and roaches in residents’ rooms and shower rooms. The administrator also brought in a commercial pest control agreement with the same company dated 8/21/25 for further treatment of the fly infestation and other covered pests.

On 8/21/25 at 2:30PM The administrator was made aware that this was still a concern because the flies and gnats are still present in the resident’s room and needed more aggressive treatment and that whatever the facility just implemented was done after surveyor’s intervention. He agreed that it was

a concern. 2) Review of complaint 337237 concerning Resident #133 on 8/27/25 at 11:09 AM revealed that the room [320] had not been painted in years and where things had been removed off the wall, the old paint was left.

Further review of the complaint revealed the bathroom water faucet was corroded and the plaster on the wall in the bathroom and other parts of the walls looked loose and flaky.

On 8/27/25 at 11:32 AM observation of room [ROOM NUMBER] revealed a ceiling tile in the corner of room ajar leaving a gap which led up to the ceiling. In addition, the top corners of the wall above the window had been patched, but had not been painted, the faucet of the bathroom sink was corroded, and the light above bed A did not have a pull cord. The current resident stated that there was no light bulb and that the light had not been working for some time.

On 8/27/25 at 11:41 AM in an interview with the Nursing Home Administrator (NHA), a dual observation of

the interior of room [ROOM NUMBER] and its bathroom was conducted. The surveyor pointed out the above observations. When asked if the findings in these observations would be considered a comfortable, homelike environment, the NHA stated no.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602

Protect each resident from the wrongful use of the resident's belongings or money.

Level of Harm - Minimal harm or potential for actual harm

Based 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.The findings include:The review of the facility investigation of intake #337244 on 8/26/25 revealed Staff #34 used Resident #104's bank card and bank account information to access money for his own benefit. Staff #34 admitted to withdrawing money at the resident's request. It was confirmed that he withdrew $100 at the request of the resident but he denied making other withdrawals. The police were called, and their investigation revealed 28 transactions starting 1/28/24 to 4/8/24 with Staff #34's name on it for withdraw via the cash app. The facility investigation file included notice of the police having signed a warrant for Staff #34's arrest. This surveyor reviewed the bank transactions from 8/1/23 to 12/31/23. On 8/1/23 there were two withdrawals from the resident's bank account to Staff #34's cash app. The amounts were $170 and $400. Review of Staff #34's employee file on 8/26/25 revealed

he was terminated on 10/11/23. The two transactions on 8/1/23 were prior to termination. Resident #104 was interviewed on 8/26/25 at 8:16 AM. This surveyor asked if the resident could explain what happened in April 2024 with staff using the bank card. Resident confirmed it happened and said there have been no more issues or incidents since April 2024. Resident went on to say that they made me go to court, but I told them to drop the charges because I don't believe in sending people to jail.This surveyor interviewed the Administrator on 8/28/25 at 8:59 AM. The Administrator said the Geriatric Nursing Assistant (GNA), Staff #34, used his cash app to transfer funds from the resident's account to his account so he could give cash to

the resident. He added that he was unaware until after the GNA was terminated that the GNA was using

the resident's ATM card as well as the cash app. He said the cash app was used by the GNA to get the resident money the resident requested. This surveyor asked if this was the usual way for residents to get money. He didn't respond directly to this question. He said that it was between the resident and the GNA.

He said that he had no way of knowing if the GNA gave the resident the money withdrawn from the resident's account. He then said the GNA was terminated and was called by him weeks after the termination to assist the resident to get the resident's money back. The surveyor stated that the facility was responsible for the actions of staff while under employment. He said, again, that he was unaware of the GNA assisting the resident to get money until after the termination. This surveyor asked why the GNA was terminated, and he replied that he did not know. This surveyor asked him to find out and to provide me with

a policy on staff obtaining money for a resident. A review of the facility policy entitled Conduct and Behavior

on 8/28/25 revealed that under section 2B a staff person may not Misuse or abuse of nursing home funds, dishonesty, theft, misrepresentation employment.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-08-28.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

F 0609 Level of Harm - Minimal harm or potential for actual harm

reporting agency, and any allegation needs to be reported. It is up to our office to decide if we are going to investigate. Telling a surveyor or getting an allegation from a surveyor does not constitute notification. He replied he understood.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610

assessment was completed on the day the incident was reported and validated that all such incidents should be investigated immediately.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Based 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.The findings includes:Review of an attachment to a complaint intake #337241 on 8/27/2025 at 10:24 AM was reviewed and the complainant stated that on 1/23/2025 the discharge papers for Resident #127 were not completely filled out.On 8/27/2025 at 10:53 Resident # 127's closed medical record was reviewed. The resident was discharged on 1/23/2025. The discharge documentation titled Engage Discharge Planning Tool was reviewed and surveyor noted that the following areas were blank:1. Section B. responsible parties' information2. Section C. Primary physician information3. Section O. Staff Signature and Residents or Responsible Party Signature4. Section R. Medication list5. Section R -Question #7. May attach pharmacy print out of medication regimen in lieu of completion of this section. Yes, No, N/A. There was no medication list, and no check off for yes, no or N/A.On 8/28/2025 at 09:57an interview was conducted with the Unit Manager, Staff # 19 who stated that the discharge paperwork engage discharge planning tool was initiated by the Social worker and the physician, nurse, Rehab, Activities, and Dietician fills out their section. Staff #19 further stated that when a resident is discharged the medication list is not printed out and the new prescribed medications are given to the residents on paper prescription and the discharging nurse would click box that medication list was not printed out. In addition, the resident or responsible party would sign a copy of the discharge paper that would be placed in the hardcopy chart.On 8/28/2025 at 10:30 AM, an

interview was conducted with the Social Worker, Staff #6 who stated that each area of the Engage Discharge Planning Tool should be filled out prior to hand off to the resident or the responsible party.At approximately 11:34 AM on 8/28/2025 the Director of Nursing was informed of the discharge documentation that was found in the medical records with blank areas. No other documentation was provided related to Resident #127's discharge. DON agreed that this was a concern.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0641 during a standard health inspection conducted on 2025-08-28.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Ensure each resident receives an accurate assessment.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the medical record that it was provided to the resident or RP.On 8/25/25 at 12:05 PM the DON provided a copy of Resident #122's BLCP; however, on the last page (6 of 6), in the Signature of Resident or Representative section, it was blank. There was no information that was inputted into the fields. Additionally,

in the Signature of Staff Completing the Baseline Care Plan section, it was also empty with no information.

A dual observation of the document was conducted and the DON verified and confirmed there was not a signature from the staff or resident/RP on the BLCP. Furthermore, the DON verified and confirmed there was no evidence from the medical record that the resident or RP received a copy of the BLCP including a list of medications. The RDCO and DON stated it was the expectation that staff completed the fields, signature of staff completing plan, title and date on the last page of the BLCP.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0657 during a standard health inspection conducted on 2025-08-28.

Category: Resident Assessment and Care Planning Deficiencies

The facility was found deficient in the following area: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

F 0676 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.01Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity. The review revealed that Resident #122 was coded each of these numbers from 09 down to 01. The resident was coded 06 which means the resident is Independent on 5 shifts during the month of October 2024; however, Resident #122 is coded in the MDS, which is what guides the level of care they require, as needing some help and supervision or touching assistance. On 8/25/25 at 12:47 PM in an interview with the Rehab Director when asked what was the expectation for a resident coded as Supervision/touching assistance, she stated that meant either eyes or a hand are on the resident. GNA #49 was interviewed on 8/28/25 at 1:19 PM. During

the interview when asked how she knows what level of assistance each resident on her assignment needs with toileting and eating she stated, We get report from the off going GNA. GNA #50 was interviewed on 8/28/25 at 1:22 PM During the interview when asked how she knows what level of assistance each resident

on her assignment needs with toileting and eating she stated, I would find that out in the computer. I would go back and click to see how it was completed on the previous shift and if they were set up last shift, that's what I'd do. On 8/28/25 at 12:16 PM in an interview with the Director of Nursing (DON) when asked how GNA's know the level of assistance residents need for eating and toileting she stated that they are told

during report. When asked if there was a place for GNAs to look in the medical record for that information,

she stated no, they are given report. The surveyor shared concerns that when reviewing the resident's medical record for toileting transfer, there was documentation that ranged all the way from dependent to independent even though the resident is coded as Supervision or touching assistance and residents not getting the required level of assistance required. The DON verified and confirmed understanding.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-28.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0686 during a standard health inspection conducted on 2025-08-28.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0690 during a standard health inspection conducted on 2025-08-28.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

1) PRN Tylenol 325mg (2 tabs) ordered without parameters for pain management, for a pain score of 6 on 8/18/2025 at 0641 (6:41 AM). 2) PRN Oxycodone HCl Oral Tablet 10 MG (Oxycodone HCl) Give 1 tablet by mouth every 4 hours as needed for pain was given on the following dates/times: - On 8/1/2025 at 7:39 (7:39 AM) and at 1749 (5:49 PM) for pain score of 6…. - On 8/3/2025 at 0008 (12:08 AM) for pain score of 6, at 0723 (7:23 AM) for pain score of 7, and at 1925 (7:25 PM) for pain score of 1. - On 8/5/2025 at 0052 (12:08 AM) for pain score of 7, at 1049 (10:49 AM) for pain score of 5, and at 2001 (8:01 PM) for pain score of 6 - On 8/18/2025 at 1703 (5:03 PM) for pain score of 8, etc.

More so, there was no documentation of non-pharmacological interventions (NPIs) attempted prior to these PRN pain meds administration.

On 8/25/2025 at 9:05 AM, an interview was conducted with Registered Nurse (RN #24) regarding administration of PRN pain medications: RN #24 stated that prior to giving any pain medication, he will assess the resident's pain and choice of pain med to be given will be based on physician orders/ordered parameters. He stated that each PRN pain med order must have a pain scale/parameters for administration: mild pain 0 -4, moderate pain 5-7, and severe pain 7-10. When asked what pain med to give

a resident that has both Acetaminophen (Tylenol) and Oxycodone ordered, RN #24 stated that he would give Acetaminophen for mild pain and Oxycodone for moderate to severe pain. He added that he would attempt non-pharmacological interventions (NPIs) such as relaxation technique, distraction, massage etc. prior to administering any PRN pain medication. RN #24 further stated that it was not appropriate to administer Oxycodone 10mg for a pain score of 1. RN #24 stated that he would educate the resident regarding pain management and if the resident insists on the Oxycodone, he (RN 24) would call the Physician and get a one-time order for the Oxycodone and document it.

On 8/26/2025 at 3:04 PM, in an interview with the Director of Nursing (DON), she stated that PRN pain meds should be given following physician orders and the PRN pain med order should have parameters (at least mild, moderate, severe pain) for administration. Regarding non-pharmacological interventions (NPIs) prior to PRN pain med administration, DON stated that staff were expected to document in their progress notes that they attempted NPIs prior to PRN pain med administration. Surveyor reviewed with the DON Resident #68’s MAR and TAR for August 2025 regarding staff PRN pain med administration (Tylenol and Oxycodone). DON verified that the PRN orders failed to have parameters/pain scale for administration.

She validated that the resident’s pain was not consistently managed and it was not appropriate to give Tylenol for a pain score of 6 and Oxycodone for a pain score of 1. However, she stated that she was going to look at the nurses' progress notes to see if they documented the reason for administering the above pain meds and/or NPI's that were attempted.

On 8/27/2025 at 7:30 AM, in a follow up interview with the DON, she stated that she could not find any nursing progress notes that indicated that NPI's were attempted prior to administering the above PRN pain meds to Resident #68. She added that there were no notes indicating why the Tylenol was given for a pain score of 6 and the Oxycodone for a pain score of 1.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0730 during a standard health inspection conducted on 2025-08-28.

Category: Nursing and Physician Services Deficiencies

The facility was found deficient in the following area: Observe each nurse aide's job performance and give regular training.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0757 during a standard health inspection conducted on 2025-08-28.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure each resident’s drug regimen must be free from unnecessary drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0761 during a standard health inspection conducted on 2025-08-28.

Category: Pharmacy Service Deficiencies

The facility was found deficient in the following area: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0791 during a standard health inspection conducted on 2025-08-28.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide or obtain dental services for each resident.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0812 during a standard health inspection conducted on 2025-08-28.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Based 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. The findings included: 1) On 08/27/2025 at approximately 5:00 PM, a review of facility reported incident #2578127 revealed that

on 07/29/2025 at 3:24 PM, Resident received a one-time dose of Narcan due to the resident unresponsiveness to call and drowsiness. The nurse contacted the physician, and he ordered a dose of Narcan to be administered to the resident.

A review of the 7/29/2025 3:36PM Nursing Progress Note stated: Narcan was administered due to sleeping excessively and resident was alert to person, place and time. Denied pain no discomfort noted. Will continue to monitor.

On 08/28/2025 at 2:10 PM, in an interview with the Director of Nursing (DON) she was asked to explain the circumstances surrounding the above-mentioned event. The DON stated that Resident #74 was sent on a leave of absence from the facility due to a family emergency. Upon the resident’s return to the facility

the resident’s behavior was significantly different. The resident’s nurse was unsure if the resident took any other medication while out of the facility as a precaution the nurse notified the physician and a one-time dose of Narcan was ordered. The medication was administered and was effective.

On 08/28/2025 at 2:32 PM, a review of Resident #74’s Medication Administration Record (MAR) for

the month of July 2025 revealed that the medication was not signed off on the MAR to indicate when the one-time dose of Narcan was administered, as required. There was also documented evidence to support that the resident’s behavior was being monitored routinely.

On 8/28/2025 at 3: 00 PM the DON was notified that the facility failed to have documented evidence to support that the Narcan administration was documented using professional standard of practice. 2) A review of Resident #127's clinical record revealed that the resident was admitted to the facility with a therapeutic boot. The resident had a consultation with the orthopedist on 11/7/23. The consultation report included a recommendation to continue using the boot to assist with weight bearing as tolerated.

The Director of Nursing was interviewed on 8/28/25 at 1:15 PM. She was asked what her expectations for nursing were when they received this consultation. She replied that she would expect nursing to follow the recommendations.

Further review of the clinical record revealed that there was no evidence that nursing staff were documenting the use of the boot on the Treatment Administration Record.

The Administrator was informed of the findings on 8/28/25 at 1:40 PM. He replied that he understood.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-28.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0881 during a standard health inspection conducted on 2025-08-28.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Implement a program that monitors antibiotic use.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0882 during a standard health inspection conducted on 2025-08-28.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.

Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0883 during a standard health inspection conducted on 2025-08-28.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Develop and implement policies and procedures for flu and pneumonia vaccinations.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

Federal health inspectors cited FREDERICK VILLA HEALTHCARE in CATONSVILLE, MD for a deficiency under regulatory tag F-F0887 during a standard health inspection conducted on 2025-08-28.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 30 deficiencies cited during this inspection of FREDERICK VILLA HEALTHCARE.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-10-03.

F 0925

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.The findings include:Review of complaint 337259 on 8/25/25 at 12:13 PM revealed that the facility was infested with roaches and rodents.The surveyor requested the facility's pest logs from 2025 on 8/27/25 at 7:42 AM. Review of the Pest Problem Log on 8/27/25 at 9:42 AM revealed the following entries in patient care areas:11/13/24 room [ROOM NUMBER]: roaches, mice11/13/24 room [ROOM NUMBER]: roaches, mice1/21/25 room [ROOM NUMBER]: roaches2/6/25 Medication room [ROOM NUMBER], 2, 3: ants, roaches, mice, mice droppings4/21/25 Rooms 118, 115, 120, 116, 117: roaches4/21/25 Rooms 217-220: roaches, mice4/22/25 Rooms 105, 106, 111, 112: roaches4/23/25 Break room: ants4/25/25 Front area: roaches5/2/25 Rooms: 207-209: water bugs5/2/25 Rooms: 100, 109: mice5/15/25 Rooms 204: spiders5/20/25 Unit 3 nurse's station: ants 5/20/25 room [ROOM NUMBER]: roaches 5/25/25 Rooms 211, 220: ants5/26/25 room [ROOM NUMBER]: bugs5/27/25 room [ROOM NUMBER]: bugs5/29/25 Rooms 211, 220: ants5/31/25 room [ROOM NUMBER]: spiders5/31/25 room [ROOM NUMBER]: ants6/1/25 room [ROOM NUMBER]: spiders6/1/25 room [ROOM NUMBER]: roaches 6/2/25 room [ROOM NUMBER]: spiders6/2/25 Rehab: roaches6/4/25 Rooms 102, 104, 106: ants, roaches6/4/25 room [ROOM NUMBER]-120: ants, roaches6/24/25 Laundry room: roaches7/16/25 Conference room: roaches, mice8/6/25 Rooms 202, 208, 314, 315: roaches, mice8/6/25 room [ROOM NUMBER]: roaches, mice8/6/25 Shower rooms 1, 2, 3: ants, roaches, mice8/8/25 room [ROOM NUMBER]: gnats8/12/25 room [ROOM NUMBER]: flies, gnats8/15/25 room [ROOM NUMBER]: flies On 8/27/25 at 8:21 AM in an interview with the Nursing Home Administrator (NHA) when asked if he has seen roaches and rodents in the facility he stated, Yes, we live in the state of Maryland and so I have seen roaches and rodents in the facility. We do have a pest management company. On 8/27/25 at 9:16 AM

in an interview with the NHA, the surveyor shared the concerns that there was a complaint filed regarding

the roaches and rodents, that the logs show sightings of roaches and rodents, and that he verified and confirmed that there are roaches and rodents in the facility. During the interview, the NHA stated this building was an old building and being surrounded by woods and water, it was a continuous effort to keep

the pests and rodents out of the building. The surveyor shared this issue was a concern and the NHA stated, sure, I understand.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/28/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Frederick Villa Healthcare

711 Academy Road Catonsville, MD 21228

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Based 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.The findings included:On 8/20/25 at 12:42 PM, the surveyor investigated Facility Reported Incident #337205. The report showed that Resident #119 claimed to have been sexually abused by a GNA of the opposite gender on 4/07/23.A further review of the facility's investigation revealed that they assessed Resident #119 and obtained statements from residents and the staff member. Resident #119 later confessed to the Nursing Home Administrator and a physician that the accusation was false.A

review of the education records for Staff #39, who was falsely accused, on 8/20/25 at 1 PM revealed the staff member was hired on 10/03/22. However, the staff members' required training, such as infection control, dementia care, and abuse training, was not completed in a timely manner. The training completion date was documented as 11/30/22.During an interview with the Nursing Home Administrator (NHA) on 8/20/25 at 2:45 PM, he confirmed that Staff #39 was hired on 10/03/22 and began caring for residents shortly after. The NHA confirmed that essential training for newly hired staff should be completed during their orientation. The surveyor shared concerns that Staff #39's training was completed two months after

the hire date, and the NHA validated the concern.

Event ID:

Facility ID:

If continuation sheet