Forestville Healthcare Center

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on record review and interviews it was determined the facility failed to investigate and take appropriate action to further prevent abuse. This was evident during the surveyor's review of facility reported incident #2635881 for Resident #2. The findings include: Resident #2's medical record review on 10/30/2025 at 9:24 AM revealed a care plan focus that Resident #2 had history of attempting to touch female staff and resident, attempting to go to female residents room and touching female residents inappropriately with interventions dated 11/03/2022 that staff were to monitor resident while in the room, redirect resident at all times and educate resident to keep his/her hands to themselves. During review of the facility reported incident #2635881 on 10/30/2025 at 9:50 AM revealed that on 09/29/2025 Resident #2 was witnessed inappropriately touching Resident #1. The facility placed a caregiver (1:1) 24 hours a day, 7 days

a week to ensure Resident #2 did not enter other residents' rooms as well as moved Resident #2 to another room.During an interview on 10/30/2025 at 10:00 AM the Director of Nursing staff #2 stated that Resident #2 had a 1:1 caregiver due to the substantiated allegation of abuse, the facility was looking to discharge Resident #2 to another facility and until he/she gets discharge will continue with a 1:1 caregiver 24 hours a day/ 7 days a week. During an interview on 10/30/2025 at 10:25 AM staff #26 stated that Resident #2 until he/she had a caregiver watching him/her had been going into other female resident rooms without supervision, touching residents and it was good that he/she had a caregiver now. During an interview on 10/30/2025 at 1:00 PM staff #9 stated that Resident #2 has had past behaviors of attempting to inappropriately touch, going into other residents' rooms of female residents prior to 09/29/2025.Review of resident #2's medical record on 10/30/2025 at 1:30 PM revealed several social worker progress notes dated from 12/5/2022 - 01/28/2025 indicating that Resident #2 had behavior problems of attempting to go into female rooms, and attempting to touch female staff and female residents.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forestville Healthcare Center

7420 Marlboro Pike Forestville, MD 20747

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

surrounding the documentation to identify medications which are liberalized, then they don't have one. On 10/31/25 at 12:10PM RNDCO #15 stated to the survey team that they would be doing a whole house resident audit to address the problem with medications not scheduled correctly within the medical orders for

the liberalized medication pass. On 11/3/25 at 10:265AM the surveyor reviewed a concern form dated 12/26/24 which revealed that Resident #24 reported a documented concern to the previous Administrator of the facility at that time, that they did not receive their short acting insulin on 12/25/24. On 11/3/25 at 11:05AM the surveyor conducted an interview of the Assistant Director of Nursing who reported that on 12/25/24 for the 3PM-11PM shift, they were both performing the role of assigned supervisor and performing

the role of working as a nurse with an assignment on the nursing floor and it is difficult to do both roles. On 11/5/25 at 9:38AM the surveyor shared concerns with the current facility Administrator who acknowledged and confirmed understanding of the concerns.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forestville Healthcare Center

7420 Marlboro Pike Forestville, MD 20747

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Based on observation and interview it was determined the facility failed to follow professional standards for food service safety. This was evident during 1 out of 1 random observations made by the surveyor during

review of complaint 292569.The findings include: On 10/30/25 at 9:32AM the surveyor reviewed complaint 292569 which included an allegation/concern for the way ice storage used for resident ice water was handled by facility staff.On 10/30/25 at 11:12AM the surveyor observed the facility's second floor nutrition room with an ice scoop holder on the wall which contained an ice scoop, however, the ice scoop was situated on top of and partially within a plastic bag which was observed stuffed within the ice scoop holder.

On 10/30/25 at 11:19AM the surveyor observed an open metal cart which contained an ice cooler on the top rack. On the bottom rack of the open style metal cart, the ice scoop for the cooler was observed stored/located approximately three inches from the hallway floor in an open plastic container with the handled ice scoop completely enclosed in a partially open plastic bag. Additionally, a container of disposable plastic drinking cups was observed on the bottom rack of the cart situated approximately three inches from the hallway floor. At this time, Medical Record Coordinator (MRC) #13 observed the surveyor conducting the observation and the surveyor shared their concerns with them. MRC #13 observed, acknowledged, and confirmed understanding of the surveyor's concern. On 10/30/25 at 12:42PM the surveyor shared concerns with the facility's Director of Nursing who acknowledged and confirmed understanding of the surveyor's concerns.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/06/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Forestville Healthcare Center

7420 Marlboro Pike Forestville, MD 20747

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

Based on observation and interview it was determined the facility failed to ensure staff performed hand hygiene. This was evident during 2 out of 2 random observations made by the surveyor during review of complaint #292569.The findings include:1.) On 10/30/25 at 9:32AM the surveyor reviewed complaint #292569 which included an allegation that a facility staff member did not perform hand hygiene prior to medication administration and they had to direct the staff member to perform hand hygiene.On 10/30/25 at 10:00AM the surveyor conducted an interview with an anonymous source who reported to the surveyor that

they observed a facility staff member administer medication with their bare hands and interact with other residents before entering their family member's room at which time they directed them to perform hand hygiene prior to working with their central line (intravenous catheter). On 10/30/25 at 10:42AM the surveyor performed a random observation of medication administration. The surveyor observed Licensed Practical Nurse (LPN) #11 proceeding down a hallway holding medication in a cup. LPN #11 then proceeded down a different hallway and entered the room of Resident #31, no hand hygiene was performed. LPN #11 administered medication to Resident #31 and was observed by the surveyor assisting the resident to get their pills into their mouth, and then placed a straw in the resident's mouth so they could drink water to swallow the pills. LPN #11 then walked out of the resident room holding the used empty cup with a straw in

it in their hand. No hand hygiene was performed upon exit from the resident's room. At this time, the surveyor shared the concern with LPN #11 who acknowledged the concern and stated, Okay, thank you.

After surveyor intervention, LPN #11 threw the cup away into the trash and performed hand hygiene. On 10/30/25 at 12:42PM the surveyor shared concerns with the facility's Director of Nursing who acknowledged and confirmed understanding of the surveyor's concerns. 2.) On 10/30/25 at 10:53AM the surveyor observed Geriatric Nursing Assistant (GNA) #12 enter Resident #32's room and bring ice water into the room with them. GNA #12 was observed moving the overbed table with their hands. GNA #12 removed the straw's wrapper for the resident's ice water and exited the room. No hand hygiene was observed to be performed by GNA #12. At this time, the surveyor shared their concern with GNA #12 who stated: Okay. On 10/30/25 at 12:42PM the surveyor shared concerns with the facility's Director of Nursing who acknowledged and confirmed understanding of the surveyor's concerns.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet