Potomac Valley Rehabilitation and Healthcare

Inspectors wroteBased on observation and interview it was determined the facility failed to ensure a homelike environment, This was evident during multiple observations by the surveyor for 1 (Unit D) out of 4 nursing units and during the surveyor's review of the environment task during the facility's recertification survey.

Inspectors wroteBased on observation and interview it was determined the facility failed to: 1.) Ensure the kitchen environment surfaces was maintained free from dust/debris, 2.) Ensure a light switch plate was maintained, 3.) Ensure cleaned dishes were stored in an area free from potential for contamination by dust/debris/chipping paint, 4.) Ensure the freezer was maintained free from accumulation of ice build up, and 5.) Follow professional standards for foods stored in refrigeration units. This was evident for 1 out of 1 facility kitchen during the surveyor's review of the kitchen task during the facility's recertification survey.

Inspectors wroteBased on observations and interviews with staff, it was determined that the facility failed to ensure that the residents' call system was functioning properly. This was found to be evident for 2 resident rooms (room [ROOM NUMBER] and #102) on Unit B during the annual recertification survey. This finding had the potential to affect all residents Unit B.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure maintenance of dignity and provide for self determination for Residents. This was evident for 2 (#150, #56) out of 42 Residents on Unit D during surveyor observation conducted in response to Complaint #3026233 and 1 (#106) out of 4 residents reviewed for dignity during the facility's recertification survey.

Inspectors wroteBased on record reviews and staff interviews, it was determined that the facility failed to ensure a resident's right to formulate an Advanced Directive. This was evident for 2 (#14, #38) out of 10 residents reviewed for Advanced Directives during the facility's annual recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews with staff, it was determined that the facility failed to maintain an environment free from restraints with the use of side rails in conjunction with a wedge and pillows for a resident. This was found to be evident for 1 (Resident # 171) reviewed for physical restraints during the annual recertification survey.

Inspectors wroteBased on record review, interviews with staff, and review of facility reported incident #2669738 it was determined the facility failed to report and ensure timely reporting of injuries of unknown origin to the Office of Health Care Quality (OHCQ). This was evident for:1.1 out of 9 facility reported incidents (#2669738)2.1 Resident (#165) reviewed for change in condition 3.1 (#144) out of 6 residents reviewed for accidents during the facility's recertification survey.

Inspectors wroteBased on recent interviews and a record review, it was determined that the facility staff failed to follow the appropriate discharge planning. This failure resulted in a delay in the community waiver program's processing of the resident's transition back to the community. This was evident for 1 (Resident #17) out of 2 residents reviewed for timely discharge planning during an annual survey.

Inspectors wroteBased on observation, record review, and interviews with residents and staff, it was determined that the facility failed to ensure a Minimum Data Set (MDS) assessment was accurately coded to reflect the resident's status. This was evident for 1 (Resident # 94) out of 3 residents reviewed for smoking and 1 (Resident #13) out of 3 residents reviewed for dental during the annual recertification survey. The MDS (Minimum Data Set) is a standardized, comprehensive assessment of a resident's functional, medical, psychosocial, and cognitive status to develop a plan of care based on the resident's individualized needs. A comprehensive MDS assessment is completed at admission, annually, quarterly, and with significant change.

Inspectors wroteBased on record review and interviews with staff, it was determined that the facility failed to ensure a resident's Preadmission Screening and Resident Review (PASARR) was reviewed after admission to the facility and revised to reflect the resident's current status. This was found to be evident for 1 (Resident #129) out of 3 resident PASARR's reviewed during the annual recertification survey. Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing facilities for long term care. PASRR requires that Medicaid-certified nursing facilities: [...]

Inspectors wroteBased on resident interviews, record reviews, and staff interviews, it was determined that the facility failed to ensure that quarterly interdisciplinary care plan meetings were held for residents. This was evident for 2 (Resident #34 and #38) out of 8 residents reviewed for care planning during the facility's annual recertification survey.

Inspectors wroteBased on record review, interviews with the resident and staff, and review of complaint #2655036, it was determined that the facility failed to ensure a resident's call bell was in reach and document and report a resident's fall and administer medications according to professional standards of practice. This was found to be evident for 1 (Resident #41) out of 6 residents reviewed for accidents and 1 (#2655036/Resident #184) out of 6 complaints reviewed during the annual recertification survey.

Inspectors wroteBased on observations, record review, and interviews with staff, it was determined that the facility failed to:1. Maintain a functional communication system for a non-English speaking resident and develop and implement a person-centered care plan to provide the best resident care.2. Provide the necessary activities of daily living (ADL) functional therapy or restorative routines required to prevent avoidable decline to ensure resident maintained the highest practicable level of physical well-being regarding ADLs needs. This was found to be evident for 2 (#171, #13) out of 4 residents reviewed for ADLs during the annual recertification survey.

Inspectors wroteBased on observations, record reviews, and interviews with staff, it was determined that the facility failed to provide an ongoing, individualized program of activities for a dependent resident that support their physical, mental, and psychosocial well-being. This was found to be evident for 2 (Resident #6 and #171) out of 3 residents reviewed for activities during the annual recertification survey.

Inspectors wroteBased on observations, record review, interviews with staff, and a review of complaint #3026233, it was determined that the facility failed to 1.) provide supervision of residents and 2.) ensure that standard electrical power strips were not used for resident's motorized beds. This was found to be evident for 1.) 1 nursing unit (D Wing) out of 4 nursing units observed and 2.) 1 (Resident #171) out of 20 residents observed on the A wing nursing unit during the annual recertification survey.

Inspectors wroteBased on interview and record review it was determined the facility failed to ensure staff followed professional nursing standards for medication administration. This was evident for 1 (#127) out of 2 Residents reviewed for hospitalization during the facility's recertification survey.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to ensure that residents were free of any significant medication errors. This was evident for 1 (Resident #172) out of 10 residents reviewed for medication errors during this annual survey.

Inspectors wroteBased on medical record reviews and interviews, it was determined that the facility failed to maintain readily accessible PASSARs in the resident's medical record. This was evident for 1 (Resident #7) out of 1 resident reviewed for PASSARs during the facility's annual recertification survey.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to ensure staff reported allegations of abuse within the required two-hour timeframe. The deficiency affected 2 (Resident #2 and Resident #6) of 6 residents reviewed for abuse or neglect.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to immediately implement interventions to protect residents during an investigation following an allegation of abuse, which affected 1 (Resident #2) of 6 residents reviewed for abuse or neglect. Specifically, Resident #2 alleged Geriatric Nursing Assistant (GNA) #2 hit them with a metal rod. GNA #2 completed their scheduled shift rather than being immediately suspended to protect residents from further potential abuse or neglect while the facility conducted an investigation.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to provide medication as ordered by the physician in a timely manner for 1 (Resident #7) of 6 residents reviewed for abuse or neglect. Specifically, Resident #7's methylprednisolone (a corticosteroid to prevent inflammation) that was ordered on 04/25/2025 was not delivered to the facility until 04/29/2025 and the resident did not receive it until 04/30/2025.

Inspectors wroteBased on interviews and medical record review, it was determined that the facility staff failed to ensure interdisciplinary team (IDT) care plan meetings were conducted and failed to update a care plan after a change in status. This was found to be evident for five (Residents #90, 100, 104, 125 and 40) out of five residents reviewed for care planning specifically, and an additional three (Residents #111, #145 and #3) out of 32 other residents reviewed during the survey.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated the residents' preferences. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on observations, record review, and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents.

Inspectors wroteBased on medical record review and interview it was determined that the facility failed to ensure residents' medical records were complete and accurately documented. This was evident for three (Resident # 104, #3 and #145) out of 37 resident's reviewed during the survey.

Inspectors wroteBased on observation and interviews it was determined that the facility failed to treat residents with dignity. This was evident for 1 resident (Resident #157) of 32 residents observed during the recertification survey.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure financial records were made available to residents through quarterly statements. This was evident for 1 (Resident #90) of 1 resident reviewed for personal funds.

Inspectors wroteBased on record review and interviews it was determined that the facility failed to offer information and education to residents regarding advance directives. This was evident for 2 residents (Resident #40, #95) of 5 residents reviewed for advance directives.

Inspectors wroteBased on observation, medical record review, and interviews, it was determined that the facility failed to ensure that Minimum Data Set (MDS) assessments were accurately coded. This was evident for 1 (Resident #32) of 3 residents reviewed for communication and sensory, 1 (Resident #119) of 2 residents reviewed for limited range of motion (ROM) and 1 (Resident #145) of 2 residents reviewed for Preadmission Screening and Resident Review (PASRR).

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to provide residents with the necessary assistance to complete an activity for daily living. This was evident for one (Resident #213) of four residents reviewed for activities of daily living.

Inspectors wroteBased on record reviews, observation and interviews, it was determined that the facility failed to ensure appropriate services and care were provided to a resident with an indwelling urinary catheter by failing to secure the urine collection bag. This was evident for 1 (Resident #142) of 2 residents reviewed for urinary catheter.

Inspectors wroteBased on observation, record review, and interview, it was determined that the facility failed to have a system in place to ensure resident's nutritional status was accurately assessed. This was evident for 1 resident (Resident #128) of 5 residents reviewed for nutrition.

Inspectors wroteBased on records review and interviews, it was determined that the facility failed to ensure pain management was provided to residents according to professional standards of practice. This was evident for 2 (Resident #43, and #512) of 3 residents reviewed for pain management.

Inspectors wroteBased on record review and interviews, it was determined that the facility failed to ensure that a resident with a history of trauma received the appropriate trauma-informed care. This was evident for one (Resident #145) out of one resident who was reviewed for mood and behavior.

Inspectors wroteBased on observation, staff interviews, and record review it was determined that the facility failed to ensure that staff accurately reconciled controlled medications using acceptable standards of practice. This was found to be evident on 2 out of 4 nursing units.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to ensure that the attending physician document in the resident's medical record included the rationale for not changing medications after being identified as an irregularity. This was evident for 1 (Resident #43) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, staff interview and record review, it was determined that the facility failed to maintain and secure controlled medications in a separately locked, permanently affixed compartment. During observation of facility medication storage refrigerators, it was observed that 1 out of 2 refrigerators were found to have an unlocked storage compartment that contained controlled medications. Controlled Medications are substances that have an accepted medical use (medications which fall under US Drug Enforcement Agency (DEA) Schedules II-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to have an effective system in place to ensure dental recommendations were followed through. This was evident for 1 (Resident #123) of 2 residents reviewed for dental care.

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to follow accepted infection control procedures. This was found to be evident for two (Resident #32 and #111) out of the 32 residents observed during the initial stage of the survey.

Inspectors wroteBased on medical record review and interview, the facility failed to provide a psychiatric evaluation for a resident that alleged abuse (resident #15). This is evident in 1 of 17 residents reviewed during a complaint survey.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to retain a complete medical record for five years from the resident discharge date for 1 (Resident #16) of 17 sampled residents.

Inspectors wroteBased on observations and staff interview, it was determined that the facility's staff failed store opened food and condiments with a to print use-by dates on opened packages and containers of food stored in the facility's kitchen freezer and refrigerator.

Inspectors wroteBased on clinical record reviews, and staff interviews, it was determined that the facility staff failed to follow an advance directive for 1 of 4 residents reviewed for advance directive care (Resident #143).

Inspectors wroteBased on the review of clinical records and staff interviews, it was determined that the facility failed to complete the required Minimum Data Set (MDS) quarterly assessment for 1 of 33 residents reviewed during the survey (Resident #1).

Inspectors wroteBased on the review of the clinical record and staff interview, it was determined that facility's staff failed to obtain a laboratory test as ordered. This finding was evident for 1 of 1 residents reviewed for the hydration care area (Resident #24).

Inspectors wroteBased on the review of residents' clinical records, and a staff interview, it was determined that the facility staff failed to provide written notification of the facility's bed hold policy to 4 of 4 residents and/or representative at the time of transfer (Resident #24, #61, #103, and #351).