Silver Spring

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure foods were labeled properly in the kitchen. The facility failed to dispose of foods after the use by / shelf-life date. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 2 (Resident #14 and Resident #79) of 81 residents reviewed for food and nutrition services. The facility failed to follow the menu for Resident #14 and Resident #79 on 01/28/2026. This failure could place residents at risk of poor intake from being disappointed they did not receive the menu items listed.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #1) of 8 residents reviewed for pain. Facility failed to ensure Resident #1's pain was recognized, properly assessed and received pain management in accordance with professional standards of practice. Facility nurse aides and occupational therapy assistant moved Resident #1 from the floor to the wheelchair to the bed, after a fall without a nurse assessing the resident for any pain or injuries on 4/8/25 at approximately 6PM. Facility nurse aides failed to relay Resident #1's pain to nurse immediately after a fall on 4/8/25 at approximately 6PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety anfor 1 of 8 (Resident #1) resident reviewed for staffing, in that: Facility failed to ensure licensed nurses and nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents need. Facility nurse aides failed to relay resident complaint of pain to appropriate nurse after a fall so that resident could be promptly assessed. Facility nurse failed to provide the on-coming nurse with information about the residents assisted fall from earlier in the day in order for resident to be monitored. Facility nurse aides and staff (PT) moved a resident after a fall without a nurse completing an assessment of resident for pain or injury. [...]

Inspectors wroteBased on interview and record review the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every 3 months for 3 of 18 Residents (Resident #1, Resident #3, and Resident #6) reviewed for assessments. The facility failed to complete a quarterly assessment for Resident #1, #3, and #6 every 3 months. This failure could place residents at risk for not getting an accurate assessment and could result in lack of care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure that spoiled food items were disposed of properly. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 4 (Resident #13) Resident's rooms observed for environmental conditions. The facility failed to ensure that Resident # 13's blinds were free from dust. The facility's failure placed the residents at risk for diminished quality of life and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in locked compartments and only authorized personnel were permitted to have access to the keys for 1 cart (medication cart Hall 500) of 3 medication carts reviewed for storage. The facility failed to ensure medication cart Hall 500 was locked and secured when unattended. These failures could place all residents at risk of harm or decline in health due to lack of , medications/biologicals or misappropriation of medications, or drug diversions.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 3 (CNA-E and LVN-F) staff observed during incontinent care and wound care. The facility failed to ensure that staff (CNA-E) performed proper peri-care (incontinent care) using improper hand hygiene for Resident #33. The facility failed to ensure that staff (LVN-F) performed proper wound care for Resident #33. These failures placed residents of the facility at risk of infections from incontinent care and wound care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 1 (Resident #1) of 5 residents reviewed for privacy. The facility failed to ensure Resident #1's BIMS score and medical diagnosis was not given to non-family or non-medical persons in the building. These failures could allow residents' protected HIPAA information to be shared with individuals who do not have a need or right to know which could place residents at a risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 2 newly admitted residents (Residents #2) reviewed for baseline care plan. The facility failed to develop a baseline care plan for Resident #2. These deficient practices could place residents at-risk for decreased quality of life, improper care, and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles, for 2 of 6 (Hall 600 & Hall 700) Medication Carts. 1.) The facility failed to ensure medication cart #1 was locked when unattended by nurse. 2.) The facility failed to ensure that all medications stored in Hall 600 & 700 medication carts were properly stored/labeled. These failures placed all residents at risk of harm or decline in health due to lack of potency of medications/biologicals or misappropriation of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to: A. dispose of food items after the use by or expiration date . B. store, seal and date food items. These failures could place residents receiving oral nutritional intake at risk for foodborne illness and a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5%. The medication error rate was 7.41% with 2 errors in 27 opportunities involving 2 staff; RN E and LVN F and 2 of 5 residents (Resident # 125 and Resident # 31) reviewed for medication errors. 1.) The facility failed to ensure RN E administered the medication Aspirin 325mg to Resident #125 as ordered by the physician. The facility administered the wrong dose 81mg to Resident #125 instead. 2.) The facility failed to ensure LVN F administered the medication Admelog SoloStar 100 unit/ML Solution to Resident #31 as ordered by the physician. The facility administered the wrong medication insulin glargine to Resident #31 instead. The facility's failure could place residents at risk of uncontrolled pain, decreased circulation, low blood sugar readings or seizures.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for 1 of 1 meal reviewed for palatability and appetizing temperature. The facility failed to serve meals that were palatable and at an appetizing temperature. These failures could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public reviewed for a safe and homelike environment for 3 (halls 500, 600, and 700) of 4 hallways. The facility failed to have residents' rooms, without damage: 1. hole in the drywall, 2. call lights did not connect to the light in the hallway, 3. scuffed paint with exposed sheetrock, 4. broken blind, 5. light string broken, 6. no toilet cover, and 7. toilet without a flushing handle. These failures could place residents and staff at risk of unsafe and unsanitary environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to preserve the resident right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 6 (Resident #31) reviewed for Resident Rights. The facility failed to respect the rights of Resident #31 regarding smokeless chewing tobacco. These failures placed residents at risk of their rights to make choices about their life being disregarded.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent residents from abuse, neglect, exploitation, and misappropriation of resident property for 1 of 15 employees (CNA-P) reviewed for criminal history checks and EMR/NAR's. The facility failed to perform an initial criminal and EMR/NAR checks for CNA-P. These failures placed residents at risk of abuse, neglect, exploitation and misappropriation of property.

Inspectors wroteBased on interviews, and record reviews, the facility failed to assure that each resident received an accurate assessment, reflective of the resident's status at the time of the assessment, for 1 of 1 (Resident #71), resident reviewed for accuracy of assessments. The facility failed to include accurate discharge for Resident #71 on MDS. This failure placed residents at risk of not receiving an accurate assessment, reflective of the resident's status.

Inspectors wroteBased on interview and record review, the facility failed to Incorporate Level II Recommendations from the PASRR level II determination and the PASRR (Pre-admission screening and resident review) evaluation for 1 of 2 residents (Resident #13) reviewed for PASRR in that: The facility failed to follow up with the LA for PASRR Level II determination when Resident #13's PASRR Level 1 Screening reflected she was positive for mental illness. This failure could place the residents with a documented mental illness, intellectual and/or developmental disability at risk for not receiving needed services.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had a discharge summary for 1 (Resident #71) of 1 resident reviewed for discharge summaries. The facility failed to ensure a dDischarge sSummary for Resident # 71 was completed which included a complete recapitulation of the resident's stay for a resident discharged to another facility. This failure could place residents discharged from the facility at risk for incorrect, incomplete, or misleading information recorded regarding discharged residents, and failure in the continuity of care for residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of any significant mediation errors for 1 of 5 residents (Resident #31) reviewed for medication administration. The facility failed to ensure LVN F administered the medication Admelog SoloStar 100 unit/ML Solution to Resident #31 as ordered by the physician. The facility administered the wrong medication insulin glargine to Resident #31 instead. This failure could place resident at risk of his medication not being administered in accordance with physician's orders, which could place resident at an increased risk of experiencing adverse effects such as low blood sugar that could lead to seizures and may be life threatening.

Inspectors wroteBased on observation, interview, and record review the facility failed to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 2 of 2 resident rooms. The facility failed to ensure call lights were connected to the light in the hallways for room [ROOM NUMBER] and room [ROOM NUMBER]. These failures could place residents at risk of receiving staff assistance for quality of care issues.