Rockville Skilled Nursing & Rehabilitation Center,

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was identified for one (Resident #58) of four residents observed during Medication Administration. Specifically, Resident #58 had a Physician's order for 150 milligrams of Topiramate (a medication to treat migraine headaches) daily. From 6/4/2024 to 6/25/2024, multiple medication nurses did not ensure the resident received the correct dosage of Topiramate 150 milligrams. Multiple nurses administered 100 milligrams and inaccurately documented that they administered 150 milligrams of Topiramate, 1.5 tablets. The finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This was identified for one (Resident #58 of four residents reviewed for Medication Administration. Specifically, on 6/3/2024, Resident #58 had a new Physician's order for Topiramate 100 milligram tablet, give 1.5 tablet (for 150 milligrams) one time a day for a diagnosis of headaches. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure that it maintained all patient care equipment in a safe operating condition. This was identified for one (Resident #161) of two residents reviewed for Pressure Ulcers. Specifically, Resident #161 had a Stage 3 pressure ulcer (full-thickness skin loss, where the damage extends into the subcutaneous tissue) and had a care plan intervention for the use of an air mattress. There were multiple observations of the low-pressure light flashing on the air mattress pump before the facility staff replaced the air mattress. The finding is: [...]

Inspectors wroteBased on record review and interviews during the Recertification and Abbreviated Survey (Complaint #NY00326729) initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #68) of three residents reviewed for Pressure Ulcers. Specifically, Resident #68 was assessed to be at a moderate risk for developing pressure ulcers. On 8/26/2023 the resident's Physician ordered a wheelchair gel cushion as a pressure relieving device. There was no documented evidence that the resident received the gel cushion until 10/19/2023. The resident was identified to have a Stage 2 sacral pressure ulcer on 10/19/2023. The finding is: [...]

Inspectors wroteBased on observations, record review, and staff interviews during the Recertification Survey initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for one (Resident # 317) of four residents reviewed for Respiratory Care. Specifically, Resident #317 was administered oxygen therapy without a Physician's order since the resident's admission to the facility on 9/28/2023 until 12/19/2023. The finding is: The facility's policy and procedure titled, Oxygen Administration, last revised on 10/20/2023 documented that oxygen use must be documented in the medical record. Oxygen therapy is administered by way of an oxygen mask, nasal cannula, and /or nasal catheter. Before administering oxygen. [...]

Inspectors wroteBased on observation, record review, and staff interviews during the Recertification Survey initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure that a physician, physician's assistant, nurse practitioner or clinical nurse specialist provide orders for each resident's immediate care and needs. This was identified for one (Resident #318) of seven residents reviewed during the Medication Administration task. Specifically, Resident #318 had a Physician's Order to administer Midodrine (medication used to treat low blood pressure); however, the order did not include blood pressure parameters regarding when to hold the medication and when to call a Physician. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00261362) completed on 12/9/2021 the facility did not consult with the resident's Physician when there was a significant change in the resident's physical or mental status for one (Resident #205) of one resident reviewed for Choices. Specifically, Resident #205 had a Physician's Order to monitor Blood Pressure (BP) weekly, and to call the Physician for a Systolic BP less than 90 millimeter of mercury (mmHg) or greater than 140 mmHg. On 7/23/2020 the resident's BP was documented as 83/46 mmHg and there was no documentation in the resident's medical record that the resident's Physician was made aware of the resident's low BP. The finding is: Resident #205 has diagnoses which include Moderate Protein-Calorie Malnutrition and Malignant Neoplasm of the Colon. [...]

Inspectors wrote2) The facility's policy, titled Pressure Ulcer-Prevention and Care, effective 5/1/2021, documented that aseptic technique is used for all dressing changes unless otherwise ordered. Resident #158 was admitted with diagnoses including left heel unstageable Pressure Ulcer and Metabolic Encephalopathy. The admission Nursing assessment dated [DATE] documented that the resident had an unstageable left heel ulcer and a Stage 3 ulcer to the left lateral lower leg. A physician's order dated 12/3/2021 documented to apply Betadine Topical Solution, one applicator full by topical route once daily to the left heel after cleaning with Normal Saline and pat dry for diagnosis of Pressure Ulcer of left heel. [...]

Inspectors wroteBased on observation, record review, and interviews during the Recertification Survey completed on 12/9/2021 the facility did not ensure that each resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for one (Resident #158) of two residents reviewed for pressure ulcers. Specifically, Resident #158 had an unstageable pressure ulcer to the left heel and had a physician's order to offload the heels. On two separate observations, the heels were not offloaded. Additionally, a wound consult recommended bilateral heel boots on 12/2/2021; however, the care plan and Certified Nursing Assistant (CNA) accountability record were not updated to include the heel boots until 12/6/2021. The finding is: [...]

Inspectors wroteBased on record review and staff interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00255243) completed on 12/9/2021, the facility did not ensure that each physician provided orders to meet the resident's care needs timely. This was identified for one (Resident #105) of one resident reviewed for Pain. Specifically, Resident #105 was admitted to the facility on [DATE] and had orders to receive Dolophine (Methadone - Opioid Analgesic) for Abdominal Pain. The medication Methadone was not available in the facility until 8/22/2019 (6 days after the Physician's order) due to a delay in the Pharmacy not receiving a narcotic prescription from the resident's Physician until 8/21/2019. [...]