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Complaint Investigation

Sligo Creek Healthcare

October 21, 2025 · Takoma Park, MD · 7525 Carroll Avenue
Citations 3
CMS Rating 3/5
Beds 102
Provider ID 215327
Healthcare Facility
Sligo Creek Healthcare
Takoma Park, MD  ·  View full profile →
Inspection Summary

SLIGO CREEK HEALTHCARE in TAKOMA PARK, MD — inspection on October 21, 2025.

Found 3 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.

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Inspection Findings

FF0573
Resident Rights Deficiencies
Potential for More Than Minimal Harm

During an interview conducted on [DATE] at 9:44 AM, the medical records staff member explained that the process for requesting medical records is as follows: once he received a request, he verified if the person is authorized to receive the medical records.

Once verified the person will complete a form.

The form is then sent to corporate who sends the request to a legal firm who approves the request.

Once approved the medical records staff member would gather the medical records and either electronically send the records or send them via mail. He stated that he kept an electronic copy of the request and medical records that were sent out.

The Medical records employee returned on [DATE] at 10:36 AM, provided this surveyor with an email that confirmed that the complainant requested Resident #8's medical records on [DATE]. He further stated that he recalled that the complainant came to facility and notified the facility that the Resident had passed away a couple of weeks ago.

The complainant requested medical records but was told that he/she must have a letter of Administration now that the Resident was deceased .

This Surveyor expressed concern that the complainant requested the medical records prior to the Resident passing away.

During an interview conducted on [DATE] at 10:40 AM, the Director of Nursing (DON) acknowledged that the complainant first requested the medical records on [DATE] prior to Resident #8 passing away, however the request for medical records was not fulfilled at the time of the request.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Sligo Creek Healthcare

7525 Carroll Avenue Takoma Park, MD 20912

SUMMARY STATEMENT OF DEFICIENCIES

Based on record reviews and interviews, it was determined that the facility failed to ensure a thorough investigation was completed for an allegation of abuse.

This was found to be evident for 3 (Resident #2, & #7) out of 4 Residents investigated for abuse during the compliant survey.The findings include: During a review of the Facility Reported Incident (FRI) # 2598686 conducted on 10/20/2025 at 9:55 AM, it was discovered that Resident #2 reported that two Nursing Assistants came into his/her room to provide care and pounded on him/her and broke the phone.

The facility's investigation included law enforcement notification, a statement from the resident, alleged perpetrators, other staff, and cognitively intact residents.

However, the facility failed to assess the cognitively impaired residents that were assigned to the alleged perpetrators.

During a review of the FRI #331192 investigation conducted on 10/20/25 at 12:59 PM, it was revealed that Registered Nurse (RN) #3 observed Resident # 11 standing beside Resident #7's bed.

She stated that she observed Resident#11 hit Resident #7 on the left side of the head with an object.During a continued review of the investigation, it was discovered that the facility obtained statements from staff and notified law enforcement but failed to interview and assess residents that may have had an interaction with Resident #11.During a review of the FRI #331177 investigation conducted on 10/21/25 at 10:20 AM, it was discovered Resident #10 reported that a Geriatric Nursing Assistant (GNA) slapped him/her in the face and sat on both of their hands while the GNA provided care. A further review of the investigation revealed that law enforcement was notified, a statement was obtained from the resident, alleged perpetrator, other staff and cognitively intact residents.

However, cognitively impaired residents were not assessed for abuse that were assigned to the alleged perpetrator.

During an interview conducted on 10/21/25 at 10:33 AM, the Director of Nursing acknowledged that cognitively impaired residents had not been included in the investigation of abuse.

She further stated that she understood the importance and would be implementing a practice that would include assessing the most vulnerable residents who were cognitively impaired when investigating abuse allegations.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Sligo Creek Healthcare

7525 Carroll Avenue Takoma Park, MD 20912

SUMMARY STATEMENT OF DEFICIENCIES

Federal health inspectors cited SLIGO CREEK HEALTHCARE in TAKOMA PARK, MD for a deficiency under regulatory tag F-F0689 during a complaint investigation conducted on 2025-10-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope/Severity Level J: isolated, immediate jeopardy to resident health or safety.

This represents an immediate jeopardy situation, the most serious level of deficiency.

This was one of 3 deficiencies cited during this inspection of SLIGO CREEK HEALTHCARE.

Correction Status: Past Non-Compliance.

The facility reported correction as of 2025-10-16.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in TAKOMA PARK, MD, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SLIGO CREEK HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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