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Complaint Investigation

Potomac Valley Rehabilitation And Healthcare

October 10, 2025 · Rockville, MD · 1235 Potomac Valley Road
Citations 3
CMS Rating 4/5
Beds 175
Provider ID 215026
Healthcare Facility
Potomac Valley Rehabilitation And Healthcare
Rockville, MD  ·  View full profile →
Inspection Summary

POTOMAC VALLEY REHABILITATION AND HEALTHCARE in ROCKVILLE, MD — inspection on October 10, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0609
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Potential for More Than Minimal Harm

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] 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Potomac Valley Rehabilitation and Healthcare

1235 Potomac Valley Road Rockville, MD 20850

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/10/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Potomac Valley Rehabilitation and Healthcare

1235 Potomac Valley Road Rockville, MD 20850

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ROCKVILLE, MD, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from POTOMAC VALLEY REHABILITATION AND HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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