Federal inspectors found that multiple staff members heard Resident #6's abuse allegations on June 9, 2025, but the facility didn't submit its initial incident report to Maryland health officials until June 12 — well beyond the required two-hour notification window.
The breakdown began when Social Services worker SS #29 documented that Resident #6 "alleged that a staff member had sexually abused them and did not want staff to touch them." SS #29 told inspectors he notified the Assistant Director of Nursing, who served as Unit Director, and the Director of Social Services about the allegation.
That same evening, Dr. #30 saw the resident in bed and noted they were "tangential about being abused from staff again." The osteopathic physician documented the encounter in medical progress notes at 5:09 PM on June 9.
But the information never reached the facility's leadership.
Dr. #30 told inspectors during an October 9 interview that "anytime staff wanted to do anything with Resident #6, the resident would say the staff were abusing them." He couldn't recall which nurse he spoke to about the June 9 allegation.
Licensed Practical Nurse #6, who was assigned to care for the resident that day, said he didn't remember the physician reporting any abuse allegations. "He stated he thought that the physician would report allegations to the Director of Nursing or Administrator," according to the inspection report.
The communication failures left administrators in the dark about a serious allegation requiring immediate investigation and reporting.
Three days later, on June 12, the facility transferred Resident #6 to the hospital because their physician said the resident was "at risk of harming their self and others." Only then did the abuse allegation surface through official channels.
A Hospital Liaison notified the Assistant Director of Nursing at 6:07 PM on June 12 that Resident #6 had alleged sexual abuse. The ADON reported this to the Administrator at 7:03 PM the same day — nearly three full days after staff first documented the resident's claims.
The facility finally submitted its initial incident report to the state survey agency at 8:40 PM on June 12, receiving email confirmation at 8:42 PM.
During her October 10 interview with inspectors, the Assistant Director of Nursing acknowledged the breakdown. She said the comments made to SS #29 and Dr. #30 "were not reported to her." Had the allegations been reported, she said, "the allegations would have been investigated and reported to the state survey agency."
The ADON admitted the June 12 report was late and said "she did not have an excuse."
The Director of Nursing told inspectors she was reviewing the progress notes from SS #29 and Dr. #30 for the first time during the October 10 interview. "She stated the remarks made to SS #29 and DO #30 that were documented in the progress notes should have been reported," the inspection found.
She also confirmed that the facility's initial report "was not reported timely."
Administrator interviews revealed the extent of the communication breakdown. After reviewing the incident report submitted on June 12, the Administrator acknowledged the facility "did not submit the report in a timely manner." Federal regulations require notification within two hours of discovering allegations of abuse.
More troubling, the Administrator said he wasn't aware of the other documentation in the resident's medical record regarding alleged abuse. "He stated it should have been reported to him so that an investigation could be completed."
The inspection found the facility violated federal requirements that nursing homes must immediately report suspected violations involving abuse, neglect, exploitation, or injury of unknown source to the administrator and other officials. The regulation also mandates that facilities report such incidents to the state survey agency within 24 hours.
Federal investigators classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. But the failure exposed significant gaps in the facility's incident reporting system and staff training on mandatory reporting requirements.
The case highlights how communication breakdowns can leave vulnerable residents without proper protection. While multiple staff members documented their interactions with Resident #6 regarding abuse allegations, the information never reached decision-makers who could have launched an immediate investigation.
The facility's own incident report acknowledged these failures, noting that proper reporting procedures weren't followed despite clear documentation of the resident's concerns.
Potomac Valley Rehabilitation and Healthcare, located at 1235 Potomac Valley Road in Rockville, serves residents requiring skilled nursing and rehabilitation services. The October 10, 2025 inspection was conducted in response to a complaint.
The delayed reporting meant that for three critical days, no formal investigation was underway into a resident's allegations of sexual abuse by staff. During that time, the resident remained in the facility's care while administrators remained unaware of the serious claims documented in medical records.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Potomac Valley Rehabilitation and Healthcare from 2025-10-10 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Potomac Valley Rehabilitation and Healthcare
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