Potomac Valley Rehabilitation And Healthcare

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

touch them. He stated that regarding Resident #6's allegation of abuse, he notified the Assistant Director of Nursing (ADON), who was the Unit Director at that time, and the Director of Social Services at that time.

Resident #6's Progress Notes revealed a Medical Progress Note, dated 06/09/2025 at 5:09 PM and electronically signed by Doctor of Osteopathic Medicine (DO) #30, that indicated the resident was seen in bed and was Tangential about being abused from staff again. During an interview on 10/09/2025 at 11:31 AM, DO #30 stated that anytime staff wanted to do anything with Resident #6, the resident would say the staff were abusing them. He stated that he did not recall the nurse he spoke to about the allegation Resident #6 made on 06/09/2025. During an interview on 10/10/2025 at 8:32 AM, Licensed Practical Nurse (LPN) #6, who was assigned to provide care to Resident #6 on 06/09/2025, stated he did not recall the physician reporting any allegations of abuse made by the resident. He stated he thought that the physician would report allegations to the Director of Nursing (DON) or Administrator. A Maryland Department of Health Office of Health Care Quality Facility Reported Incident Initial Report Form, dated 06/12/2025, indicated the facility transferred Resident #6 to the hospital on [DATE REDACTED] due to the resident's physician stating the resident was at risk of harming their self and others. The document indicated that the ADON was notified by the Hospital Liaison on 06/12/2025 at 6:07 PM that Resident #6 alleged that they had been sexually abused. Per the document, the ADON reported the allegation to the Administrator on 06/12/2025 at 7:03 PM. The document revealed that it was submitted to the state survey agency on 06/12/2025 at 8:40 PM. An email to the ADON, dated 06/12/2025 at 8:42 PM, revealed confirmation that the initial report was received.During an interview on 10/10/2025 at 11:07 AM, the ADON stated the comments made to SS #29 and the DO #30 were not reported to her. She stated that if the allegations had been reported to her, the allegations would have been investigated and reported to the state survey agency. She stated that the report she sent to the state survey agency for Resident #6 on 06/12/2025 was late and she stated that she did not have an excuse. During an interview on 10/10/2025 at 11:40 AM, the DON reviewed the progress notes from SS #29 and DO #30 and stated the remarks made to SS #29 and DO #30 that were documented in the progress notes should have been reported. She stated that it was the first time she had been aware of the documentation. She also stated that the initial report submitted on 06/12/2025 was not reported timely. During an interview on 10/10/2025 at 12:26 PM, after reviewing the initial report submitted to the state survey agency on 06/12/2025, the Administrator stated the facility did not submit the report in a timely manner. He stated it should have been reported within two hours. The Administrator stated he was not aware of the other documentation in the resident's record of alleged abuse. He stated it should have been reported to him so that an investigation could be completed.

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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

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Potomac Valley Rehabilitation and Healthcare

1235 Potomac Valley Road Rockville, MD 20850

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 0610 Level of Harm - Minimal harm or potential for actual harm

Resident #2 made the abuse allegation. The DON further stated GNA #2 should have been sent home immediately after Resident #2 made the abuse allegation. The DON stated it was an oversight on management's part. During an interview on 10/10/2025 at 11:53 AM, the Administrator stated GNA #2 was suspended pending investigation, but she should have been sent home immediately once the allegation was made instead of staying until she completed her shift at 7:00 AM.

Residents Affected - Few

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

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

10/10/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Potomac Valley Rehabilitation and Healthcare

1235 Potomac Valley Road Rockville, MD 20850

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

stated they had a hard time getting Resident #7's methylprednisolone because of the listed allergy. The DON stated the nurses were calling to get the medication, and the pharmacy told them that it would be on

the next delivery, but then not send it. The DON stated CRNP #25 finally talked to the pharmacy, and that was when they sent it. During an interview on 10/10/2025 at 11:40 AM, the DON stated that if a medication were not available from the pharmacy to administer, the nurse should call the pharmacy immediately to see what was going on and then update the practitioners to see if there was an alternate medication that could be used. The DON stated the charge nurse, then the unit manager, then the ADON, and the DON should follow up concerning the missing medications. The DON stated steroids should be tapered and not be stopped abruptly, to prevent an adverse effect to the resident. The DON stated everyone that handled a new order should be checked for allergies, and if a resident was prescribed a medication that they had an allergy to, the medication should not be administered until it was discussed with the physician. The DON stated staff needed to ask the resident or family what type of reaction the resident had to the medication.

The DON stated staff had followed up on the steroid medication for Resident #7 almost daily but probably should have been more aggressive about it. During an interview on 10/10/2025 at 12:26 PM, the Administrator stated that if a medication were not available from the pharmacy, the nurse should reach out to the pharmacy to see when they could get it. The Administrator stated there should be an immediate call to the pharmacy, and it was the responsibility of the nurses to follow up. The Administrator stated nursing staff should be checking for allergies, and if a resident was prescribed a medication that they were allergic to, the physician should be notified to make the decision to change the order.

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