The Village at Rockville

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure residents were treated in a manner that maintained dignity. This was evident for 2 (Resident #168 and Resident #57) out of 12 residents observed.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to ensure that 1) the environment was in good repair in 3 (Resident rooms #3142, #3145, & #3147) out of 32 Resident rooms and 2) Residential hot water temperature was safe in 5 (#2390, #2391#2220, #2215, and #2212) out of 5 Resident rooms observed for the environment during the recertification and complaint survey.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure food items were stored in accordance with professional standards for food service safety. This was identified during the kitchen facility task conducted as part of the annual/complaint survey.

Inspectors wroteBased on record reviews and interviews, it was determined that the facility failed to thoroughly investigate a resident's allegation of abuse. This was evident for 2 (Resident #74 and Resident # 140) of 4 residents reviewed for abuse during the annual recertification and complaint survey.

Inspectors wroteBased on medical record reviews and interview, it was determined that the facility failed to complete a significant change Minimum Data Set (MDS) assessment within 14 days of the resident's disenrollment in hospice services. This was evident for 1 (Resident #43) out of 2 residents reviewed during recertification survey process.

Inspectors wroteBased on interviews and record reviews it was determined that the facility failed to ensure a Resident care plan was developed. This was found to be evident for 1 (Resident #166) out of 32 Resident care plans reviewed during the recertification and complaint survey.

Inspectors wroteBased on record reviews and interviews it was determined that the facility failed to provide services that met professional standards of practice. This was found to be evident for 1 (Resident #166) out of 1 Resident reviewed for professional standards of practice during the recertification and complaint survey.

Inspectors wroteBased on record review and interview, it was determined that the facility failed to ensure that a resident received care that met acceptable standards of quality. This was evident for 1 (Resident #6) out of 1 resident reviewed during review of a facility reported incident.

Inspectors wroteBased on medical record reviews and interviews it was determined the facility staff failed to follow procedures for Residents with a pressure ulcer. This was evident for 2 (#7 & #122) out of 2 residents reviewed for pressure ulcer care during the recertification survey.

Inspectors wroteBased on observations, record reviews and interviews it was determined that the facility failed to keep residents free from injury. This was evident for 1 (Resident #10) of 1 resident reviewed for injuries during the annual recertification survey.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on record review and staff interviews, it was determined that the facility failed to provide Cardiopulmonary Resuscitation (CPR) to an unresponsive resident whose active Maryland Orders for Life Sustaining Treatment (MOLST) instructed to Attempt CPR if cardiac and/or pulmonary arrest occurs. This was evident for 1 (#137) of 21 residents reviewed for abuse during the survey. This deficient practice led to an immediate jeopardy for Resident #137 on [DATE]. Following the incident, the facility implemented effective and thorough corrective measures. The facility's plan and action were verified during this survey; therefore, this deficiency was cited as past noncompliance. The date of correction was [DATE].

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wrote1b) 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on surveyor observation(s), review of clinical records, facility policies and procedures, and resident and staff interview(s), it was determined that facility staff failed to implement preventive measures to prevent a pressure injury for residents identified at low (mild) or moderate risk for impaired skin integrity. These failures resulted in 3 of 3 residents with facility acquired pressure injuries that were reviewed during the survey (#105, #221 and #11). On 10-21-19 at 4:15 PM, an immediate jeopardy (IJ) for residents at low (mild) to moderate risk for pressure injury was determined. On 10-21-19 at 6:43 PM, the facility staff submitted an IJ removal plan related to residents at low (mild) to moderate risk for pressure injury to the Office of Health Care Quality (OHCQ) which was accepted. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased on surveyor review of clinical records and interview with facility staff, it was determined that the facility failed to develop and implement a complete baseline care plan within 48 hours of a resident's admission. This finding was evident for 1of 5 residents selected for review of the unnecessary meds care area.(#71)