The Village At Rockville

Based on observation, record review and interview it was determined that the facility failed to ensure a Resident's enteral feeding was labeled. This was found to be evident for 1 (Resident #34) out of 1 Resident observed for tube feeding during the recertification and complaint survey. The findings include: Enteral feeding, or tube feeding, delivers liquid nutrition directly into the stomach or small intestine via a tube for individuals with a functioning gut who cannot consume enough calories orally. It is used for short-term (<4-6 weeks, e.g., nasogastric) or long-term support (e.g., G-tube/PEG) to treat malnutrition, swallowing difficulties, or critical illness.A gastrostomy tube (G-tube) is a medical device inserted through the abdomen into the stomach to deliver nutrition, fluids, and medication directly, bypassing the mouth and esophagus. It is used for individuals, often children, with swallowing difficulties, chronic illness, or failure to gain weight.During an observation conducted on 02/25/2026 at 9:45 AM, the Surveyor observed Resident #34 in bed asleep, head of the bed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews it was determined that the facility failed to ensure staff practiced infection control. This was evident for 4 (Residents #138, #3, #65 and #131) out of 6 Residents observed for infection control during the recertification survey.The findings include: 1) Enhanced Barrier Precautions (EBP) are infection control measures in nursing homes requiring staff to wear gowns and gloves during high-contact care for residents at high risk of spreading multi-drug-resistant organisms (MDROs). They prevent transmission of resistant bacteria like C. auris or MRSA, especially for those with wounds or medical devices. On 02/25/2026 at 9:32 AM The Surveyor observed a sign on the Resident's entry door for Enhance Barrier Precaution (EBP). The Surveyor entered the Resident's room and observed GNA/PDA #30 cleaning Resident #138's face with a white cloth. The GNA/PDA was not wearing gloves and a gown while she provided high contact care. During an interview GNA/PDA #30 stated that she was familiar with EBP that was why she washed her hands before and after providing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that the facility failed to ensure that direct care staff had mandatory communication training. This was evident for 8 staff (#15, #17, #18, #19, #20, #21, #22, #23), of 8 staff training records reviewed for communication training during the extended survey portion of the recertification survey. The findings include: On 10/08/24 at 10:34 AM, eight randomly selected employee files were requested as part of the staffing facility task of the standard survey, and included Geriatric Nursing Assistants, Licensed Practical Nurses, and a Registered Nurse. On 10/09/24 at 3:53 PM, the extended survey task was triggered due to an Immediate Jeopardy situation determined during the standard survey. As a result, the survey team determined the need to review the randomly selected direct care staff for evidence of communication training. On 10/10/24 at 9:10 AM, a record review revealed a lack of evidence of communication training for GNA #15, GNA #17, GNA #18, GNA #19, GNA #20, and LPN #21, LPN #22, and RN #23. On 10/11/24 at 11:55 AM, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that the facility failed to 1) report allegations of abuse within two hours, and 2) identify and report potential abuse to the administrator. This was evident for 1) four facility reported incidents (FRIs) (#MD00202347, #MD00198954, #MD00181634, MD00187540) of seventeen FRIs, and 2) one (Resident #33) of twenty-one residents reviewed for potential abuse. The findings include: 1a) On 10/08/24 at 11:55 AM, a review of the facility reported incident #MD00202347 revealed that Resident #36's responsible representative made the facility aware of an allegation that female residents on the second floor were being compromised at night. Staff were made aware of the allegation on 2/06/24 at 3:15 PM, but failed to report the allegation to the Office of Healthcare Quality until 2/07/24 at 6:07 PM. On 10/09/24 at 8:24 AM, the surveyor reviewed the concern with the Director of Nursing (DON) regarding the failure to report an allegation of abuse within 2 hours. 1b) On 10/09/24 at 9:03 AM, a review of the facility self reported incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview with facility staff, it was determined that the facility failed to obtain informed consent prior to the initiation of bed rails. This was evident for 2 (Resident #23 and #120) of 4 residents reviewed for physical restraints. The findings include: Bedrails or side rails are adjustable bars that attach to the bed. They vary in size, including full, half, and quarter lengths depending on their intended purpose. They can be used to prevent falls, help assist residents with movement, and provide a feeling of security. Bed rails also have potential risks associated with them. The facility should obtain a signed consent form before the use of bedrails. 1) On 10/02/24 at 9:59 AM, the surveyor observed Resident #120 in bed with two bed rails up on either side of the top end of the bed. On 10/03/24 at 11:33 AM, a review of Resident #120's medical record failed to reveal a consent form for the bed rail use. On 10/09/24 at 7:47 AM during an interview with the Director of Nursing (DON), the DON explained that the facility used enabler quarter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that the facility failed to ensure the pharmacists recommendations regarding medications irregularities were communicated to the resident's physician. This was evident for three residents (Resident #51, # 111, and #117) of 5 residents reviewed for unnecessary medications during a survey. The findings include: 1) On 10/04/24 at 9:30 AM, Resident #51's medical records were reviewed. The review revealed that Resident #51 was a long-term resident at the facility and was receiving multiple medications. Further review revealed that a pharmacist reviewed Resident #51's medications for irregularities every month from November 2023 through September 2024. On 10/04/24 at 10:09 AM, a review of progress notes revealed a pharmacy note, dated 11/06/23, that indicated Resident #51's medications were reviewed and included that statement See report for any noted irregularities and or recommendations. On 10/04/24 at 12:20 PM, the Director of Nursing (DON) was interviewed and reported that she was unable to provide the 11/06/23 pharmacy report…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, it was determined that the facility failed to respond timely when residents called for assistance. This was evident for 1 complaint (#MD00206835) of 6 complaints reviewed during the recertification survey. The findings include: On 10/08/24 at 3:00 PM, a review of complaint #MD00206835 was conducted. It alleged that staff were slow to answer Resident #152's call bell on 11/20/23, 11/21/23, 11/25/23, 11/26/23, and 12/04/23. On 10/11/24 at 10:15 AM - the Nursing Home Administrator (NHA) was asked to provide the call bell response log for Resident #125 for the days of concern. A review of those records revealed that on 11/20/23, 11/21/23, 11/25/23, 11/26/23, and 12/04/23, Resident #152's call bell went unanswered for 42 minutes or longer at least once. On 11/20/23, 11/25/23, and 12/04/23, this occurred twice. On 10/11/24 at 10:20 AM in an interview with Geriatric Nursing Assistant (GNA #13), she described how the call bell system worked. She said that when the resident pressed their call device, the GNAs received a phone notification on an app. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview with facility staff, it was determined that the facility failed to ensure that a primary care provider was notified of a lab result. This was evident for 1 (Resident #120) of 3 residents reviewed for urinary tract infections. The findings include: On 10/02/24 at 1:42 PM, review of Resident #120's electronic medical record revealed a urine culture and sensitivity result from the lab, dated 9/20/24 at 12:00 PM, which indicated the urine specimen was spilled in transit and that Registered Nurse, Staff #14 was informed. On 10/08/24 at 9:19 AM, an interview with the second floor Registered Nurse Care Coach/Unit Manager (Staff #1) revealed that the responsibility of the nurse with lab results is to review and notify the primary care provider of the results. Further interview revealed the nurse should document the communication with the provider of the result and the provider response. Further review of Resident #120's medical record failed to reveal any documentation to indicate that the urine was spilled in transit was communicated to a primary care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 1b) On 10/04/24 at 12:30 PM, a random observation in the Potomac hallway bathroom, located across from the 2nd-floor dining room, revealed a hole in the wall opposite the toilet. Further observation revealed that the hole in the wall was in the shape of the bathroom door's handle. The hole was approximately 7 inches long, and the widest portion was 3- 1/2 inches. Continued observation revealed that the hole was stuffed with toilet paper. A second observation of the same Potomac Hall bathroom on 10/10/24 at 12:35 PM, revealed no change in the hole in the wall. On 10/10/24 at 1:25 PM, the Maintenance Director (Staff #12) and surveyor made a joint observation of the hole in the wall of the Potomac hallway bathroom. The hole in the wall was filled with toilet paper. Staff # 12 stated that he was unaware that the hole was there and said that it would be repaired immediately. On 10/10/24 at 4:20 PM, in an interview with Staff #12 and the Nursing Home Administrator, they reported that repair of the hole in the wall was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of medical records and facility reported incident investigation documentation and interviews, it was determined that the facility failed to keep a resident free from abuse. This was found to be evident for one (Resident #33) of twenty-one residents reviewed for potential abuse. The findings include: Review of Resident #33's medical record revealed the resident required staff assistance with transfers from bed to wheelchair and back to bed. Review of a facility reported incident (MD00189254) revealed that, on 2/19/23 the geriatric nursing assistant (GNA Staff #15) refused to assist the resident back to bed when the resident requested assistance. Review of an interview with Resident #33, dated 2/21/23, revealed that, on 2/19/23, the resident was in the dining room for lunch. After lunch the resident asked GNA #15 to take them back to their room. The GNA said no, and indicated that, when she (the GNA) was ready she would take the resident back. The resident then told the GNA that his/her legs hurt and that he/she wanted to go back to his/her room. The GNA again refused…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility reported incident investigations and interview, it was determined that the facility failed to thoroughly investigate allegations of abuse. This was evident for 1 (#138 ) of 21 residents reviewed for abuse. The findings include: On 10/10/24 9:40 AM, a review of facility reported incident, MD00187540 was conducted. The facility's initial self-report documented that, on 1/9/23, a family member of Resident #138's reported to a supervisor that Resident #138 alleged s/he was abused and retaliated against by staff assigned to the resident. Review of the documents included with the facility's investigation revealed documentation of interviews that were conducted with staff members assigned to the resident during the time frame the alleged abuse was reported to have occurred, and interviews conducted with some residents. However, continued review of the facility's investigation failed to reveal documentation of the interview conducted with the family member who reported Resident #138 had an allegation of abuse. In addition, there was no documentation in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews and record review, it was determined that the facility failed to include the resident care plan with the required documentation during a transfer. This was evident for 1 (Resident #45) of 3 residents reviewed for hospitalization. The findings include: On 10/03/24 at 10:41 AM, record review revealed that Resident #45 was hospitalized on [DATE] and 4/22/24. On 10/07/24 at 12:33 PM, an interview with Licensed Practical Nurse (LPN #28) and Licensed Practical Nurse (LPN #29) revealed that the nurses use a transfer checklist to ensure required documents are sent with the resident upon a transfer. Review of the transfer form checklist provided to the surveyor during the interview failed to reveal indication of a care plan. Further interview with LPN #28) and LPN #29 revealed that they would not send the residents care plan upon transfer. On 10/07/24 at 1:26 PM in an interview with the Director of Nursing (DON), she said that the care plan should be sent with the residents upon transfer. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to provide written notification of transfer to the resident and resident representative. This was evident for two residents (Resident #45, #98) of 3 residents reviewed for hospitalization. The findings include: 1) On 10/03/24 at 10:41 AM, a review of Resident #45's medical record revealed she/he was hospitalized on [DATE] and 4/22/24. Further review of Resident #45's electronic medical record and paper chart on 10/03/24 at 10:45 AM, failed to reveal a that a written transfer form was provided to the resident and resident representative for the 2/2/24 and 4/22/24 hospitalizations. On 10/07/24 at 1:13 PM in an interview with the Nursing Home Administrator (NHA), she said that the hospital transfer notice forms were typically not given to the resident, but the resident representative would verbally be told of the transfer. If the responsible representative was local and wanted a copy, then the facility would send a copy, but the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, it was determined that the facility failed to orient, prepare, and document a resident's transfer. This was evident for two (Resident #45, #98) of 3 residents reviewed for hospitalization. The findings include: 1) On 10/03/24 at 10:41 AM, a review of Resident #45's medical record revealed that he/she was hospitalized on [DATE] and 4/22/24. On 10/09/24 at 8:24 AM, in an interview with the Director of Nursing (DON), she said that when a resident was sent to the hospital, the documentation of the residents transfer was written in the progress notes. On 10/09/24 at 8:24 AM, further interview with the DON on 10/09/24 at 8:24 AM revealed that the facility also used a transfer form where they documented the reason for the residents transfer and that the resident representative was notified of the transfer. On 10/09/24 at 8:25 AM, the surveyor reviewed progress notes around the two dates of hospitalization and the transfer form completed for Resident #45's hospital transfers…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, it was determined that the facility failed to notify the resident and/or the resident representative in writing of the bed-hold policy upon transfer of the resident to an acute care facility. This was evident for 2 (#98, #45 ) of 3 residents reviewed for hospitalization. The findings include: On 10/7/24 at 12:35 PM, a review of Resident #98's electronic medical record (EMR) revealed documentation that Resident #98 was transferred to an acute care facility on 9/29/24. In an SBAR (acronym for situation, background, assessment, recommendation; used to facilitate communication between health care members), on 9/29/24 at 9:55 AM, the nurse documented that Resident #98 had a change in condition, that the resident was having difficulty breathing, the resident was alert and responsive, the physician was notified, and ordered the resident transferred to the emergency room for respiratory distress. In an admission note on 10/2/24 at 4:08 PM, the admissions manager documented Resident #98's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, it was determined that facility staff failed to develop and implement comprehensive resident centered care plan plans for residents. This was evident for 1) one (#118) of 5 residents reviewed for unnecessary medications, and 2) one (Resident #120) of 3 residents reviewed for communication during the recertification survey. The findings include: A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care. Staff utilize care plans to provide resident centered care that includes support, services, and resources to address the needs of a resident. 1) Psychosis is a condition that causes a person to lose touch with reality, making it difficult to distinguish what is real and what is not. It is a term used to describe a group of symptoms, rather than a diagnosis. Symptoms include hallucinations, delusions (false beliefs) disorganized thinking or speaking; difficulty trusting others, and withdrawing from others. On 10/3/24 at 2:02 PM, a review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, it was determined that the facility failed to ensure that only licensed staff fed residents. This was evident for 1 resident (Resident #39) of 32 residents observed during the recertification survey. The findings include: On 10/02/24 at 12:47 PM, an observation of the 2nd floor Potomac Unit dining room was conducted. Resident #39 was sitting in a wheelchair at a table with 3 other residents. An unidentified female without a name badge stood next to Resident #39, took a spoonful of food from the resident's tray and placed it in the resident's mouth, then walked away. The unidentified female returned at 12:53 PM, fed the resident one bite and walked away. The same female returned at 12:55 PM, fed the resident another bite, and walked away again. Multiple other facility staff were present in the dining area and in the hallways during this time. On 10/02/24 at 12:58 PM, an interview was conducted with Geriatric Nursing Assistant (GNA #3) who was in the hallway next to the dining room. When asked, GNA #3 reported that the female who fed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, it was determined the facility failed to keep a resident's drug regimen free from unnecessary drugs by failing to ensure orders had adequate parameters in place to indicate when to administer as needed medications for constipation. This was evident for 1 (#118) of 5 residents reviewed for unnecessary medications. The findings include: On 10/4/24 at 10:10 AM, a review of Resident #118's medical record was conducted. Review of Resident #118's September MAR revealed 3 medications to be administered as needed for constipation with no clear indication of when to give which one, and 2 of these orders were for the same medication. There was a 9/10/24 order for lactulose oral solution (laxative) by mouth every 12 hours as needed for constipation, a 9/10/24 order for Miralax Powder (Polyethylene Glycol) (laxative)17 GM (grams) by mouth every 24 hours as needed for constipation once a day as needed for no BM (bowel movement), and there was a 9/10/24 order for Polyethylene Glycol Powder, 17 GM by mouth every 24 hours as needed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review and staff interview, It was determined that the facility failed to ensure that a resident's medication regimen was free from an unnecessary psychotropic medication by 1) failing to adequately monitor a resident for behavior, side effects or adverse consequences related to psychotropic medication use. This was evident for 1 (118) of 5 residents reviewed for unnecessary medications. The findings include On 10/3/24 at 2:02 PM, a review of Resident #118's medical record was conducted and revealed the resident was admitted to the facility in early September 2024 following an acute hospitalization. Review of the resident's admission assessment, with an assessment reference date of 9/14/24, documented Resident #118 had moderate cognitive impairment, medically complex conditions, and multiple medical diagnoses which included dementia, anxiety disorder, and depression. The assessment also documented that Resident #118 was taking an antipsychotic, and an antidepressant, and received antipsychotics on a routine basis. Review of Resident #118's September 2024…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, it was determined that the facility failed to properly store food items to prevent cross contamination. This was evident for two random observations of the facility's freezers and refrigerators. The findings include: On 10/2/24 at 9:09 AM, the surveyor toured the main kitchen with the Dining Services Supervisor (Staff #33). During the observation of the walk-in freezer, the surveyor noticed what appeared to be a sausage wrapped in plastic on the shelf. This item lacked a label or date. Staff #33 removed the item from the freezer at the time of the observation. On 10/4/24 at 2:43 PM, during an observation of the second-floor kitchen in the Maryland unit, the surveyor observed one metal container with red sauce in it, the container did not have a cover or a label. A second metal container was observed with an open bag of sour cream that was 3/4th full and a serving scoop was noted to be sitting in the sour cream. Staff # 35, a dining server, was then shown the containers and identified the red sauce as salsa and reported it was served with tacos…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, it was determined that the facility staff failed to keep complete and accurate medical records by failing to void a residents MOLST form when an updated MOLST form was completed. This was evident for 3 (#114, #118, #10) of 11 residents reviewed for advanced directives. The findings include: Maryland Orders for Life Sustaining Treatment (MOLST) is a medical order form covering options for cardiopulmonary resuscitation (CPR) and other life-sustaining treatments. The medical orders are based on a patient's wishes about medical treatments. It is valid in all healthcare facilities and programs throughout Maryland. Section 1 includes orders to Attempt CPR or No CPR. Included in the No CPR section are three options: A-1 Intubate; A-2 Do Not Intubate but comprehensive efforts may include limited ventilatory support by CPAP or BiPAP; or Option B No CPR, Palliative and Supportive Care, do not intubate or use CPAP or BiPAP. The MOLST form shall be voided and a new MOLST…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interviews, it was determined that the facility failed to use appropriate infection control practices. This was evident for one (Resident #125) of two residents reviewed for urinary catheter use. The findings include: On 10/3/24, at 11:00 AM, a review of the records showed that Resident #125 had an order for an indwelling Foley catheter, which is used to drain urine from the bladder into a collection bag. On 10/3/24 at 11:09 AM, the surveyor observed Resident #125 lying in bed. The foley catheter bag was observed lying flat on the floor. On 10/3/24 at 11:12 AM, surveyor and the nurse (Staff #25), entered Resident #125's room, and the nurse confirmed the observation of the resident's Foley catheter bag lying flat on the floor. Staff #25 acknowledged that the Foley catheter bag should not be in contact with the floor. She then raised the bed to ensure that the catheter was no longer touching the floor and mentioned that someone had most likely lowered the bed to its lowest position.

Based on record review and interviews, it was determined that the facility failed to ensure that residents or their representatives were educated on the risks and benefits of pneumonia vaccinations. This was evident for 2 (#28, #129) of 5 residents reviewed for immunizations during the survey. The findings include: 1) Record review on 10/10/24, at approximately 8:16 AM, of Resident #28's immunization record noted that consent refused. The continued review contained a vaccination consent form, signed on 6/17/24, and documented that I do not give permission for any vaccines to be administered. Further review failed to show documentation that Resident #28 and his/her representative were fully informed of the health benefits and risks of receiving vaccinations. 2) Record review for Resident #129 showed that s/he was admitted to the facility in August 2024. Further review revealed that Resident #129's representative refused a pneumococcal vaccination on 8/26/24. However, the review failed to show that education was provided on the risks and benefits of vaccination. In an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of the clinical record, it was determined that the facility staff failed to revise the plan of care to reflect the preventive measures for pressure injury in residents utilizing splints and/or braces. This finding was evident for 2 of 2 residents utilizing splints/braces that were reviewed during the survey. ( #99 and #221). The findings include: 1. Resident #99 was admitted to the facility on [DATE] and on 08-28-19 the facility staff obtained a physician's order for a back brace to be worn every day when the resident was out of bed. Review of the plan of care for resident #99 on 10-21-19 revealed a care plan for altered skin integrity related to skin tears. The facility staff failed to revise the care plan to reflect the potential for pressure injury related to daily use of the back brace until 10-22-19. On 10-22-19 the care plan was revised to reflect the potential for pressure injury related to immobility and the use of the back brace. Surveyor interview with DON on 10-21-19 at 1:30 PM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor review of the clinical record, and facility staff interviews, it was determined that the facility staff failed to develop and implement a comprehensive person-centered care plan to meet a resident's clinical and psychological needs. This finding was evident for 2 of 45 residents reviewed during the survey. (#70, #90) The finding includes: 1. On 10-16-19 at 10:30 AM, surveyor review of resident #70's medication administration record (MAR) revealed that resident #70 was taking multiple medications including, but not limited to, antidepressant medications (medications used to treat major depressive disorders). Further review of the physician order sheet (POS) revealed that the medication was ordered on July 24th, 2019. Additional record review revealed a psychiatrist documentation in August, September and October 2019, indicated the rational/diagnosis for the medication. However, there was no evidence that the facility staff initiated a care plan to address resident #70's antidepressant medication usage. Neither were there interventions put in place to address the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of the clinical record and surveyor observation, it was determined that the facility staff failed to ensure the accurate acquiring/receiving of medication from an authorized source. This finding was evident for 1 of 32 records reviewed during the initial pool. (#92) The findings include: On 10-15-19 at 11:30 AM, review of the clinical record for resident #92 revealed physician's orders, dated 10-10-19 at 2:13 PM, for Aranesp injection. (medication used to treat anemia) with instructions family supplied. The physician's order did not provide instructions on holding the medication if the hemoglobin was greater than or equal to a certain level. On 10-15-19 at 2:37 PM, surveyor observed a Giant grocery store bag in the medication refrigerator which contained a syringe labeled with resident #92's name. The charge nurse of the 3 Virginia nursing unit identified the medication as the family supplied Aranesp, which facility staff were administering to the resident. The 3 Virginia charge nurse stated that, to her knowledge, the syringe had not been verified (by the pharmacy…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on surveyor observation and facility staff interviews, it was determined that the facility staff failed to label drugs and biologicals in accordance with accepted professional standards. This was evident for 1 of 5 medication storage rooms selected for medication storage inspection during the survey. (3 Maryland nursing unit) The findings include: On 10-17-19 at 10:31 AM, surveyor observed a vial of tuberculosis(TB) skin test in the refrigerator with an open date marked 09-02-19. Based on facility practice and professional standards the vial should have been discarded 30 days after it was initially opened. (10-02-19). In addition, there was an open vial of pneumonia vaccine with no open or discard date on it. Finally, surveyor observation of phlebotomy tubes (used to draw blood for lab testing) were checked for expiration dates. There were 10 blue top tubes with expiration date 06-30-2019 and 6 yellow top tubes with expiration date 09-30-19. Upon surveyor intervention, the 3 Maryland charge nurse discarded the expired tubes. On 10-17-19 at 11:31 AM, interview with director of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.