Layhill Nursing And Rehabilitation Center
Inspection Findings
F-Tag F609
F-F609 and 610
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31982
Residents Affected - Some Based on review of facility documentation and interview with staff it was determined the facility staff failed to ensure that allegations involving abuse were reported to the Administrator of the facility and the State Agency no later than 2 hours after the allegation was made and results of all investigations were reported within 5 working days. This was evident in 5 of 27 abuse allegations reviewed for Residents (#1, #2, #7, #62, #3 ).
The findings include:
1. Facility Reported Incident (FRI) #MD00186593 related to an allegation of abuse involving Resident #1 was reviewed on 6/11/24 at 12:50 PM. The Date/Time of the incident in the facility's report was 12/9/22 11:45 AM and the police report was 12/9/22 at 11:45 AM. The facility's email containing the Initial self-report was dated 12/9/22 2:36 PM. It was not sent to the State Agency within 2 hours of the allegation.
2. The facility's investigation documentation for FRI #MD00196546 was reviewed on 6/13/24 at 11:13 AM.
The report indicated that the Director of Nursing (DON) received an email from Resident #1's family member
on 9/5/23 alleging that a staff member was abusive toward Resident #1. The facility's initial report was submitted to the State Agency on 9/5/23. Staff statements obtained by the facility during their investigation revealed that the alleged incident occurred at approximately 3:00 AM on 8/31/23, 5 days prior to the date it was reported to the state agency. The email from the Resident #1's family member was not included in the facility's investigative documentation.
At 12:46 PM on 6/13/24, the surveyor requested and received a copy of the email from the resident's family member. The email was dated 9/5/23 10:59 AM and was addressed to numerous recipients which included but were not limited to the facility's former DON (Staff #31) and former Administrator (#24). The email indicated that 2 issues were resolved and asked that the facility fully address the 3rd issue immediately and referenced the incident on the night shift of 8/30/23 - 8/31/23. It included, It's been several days since my initial call to you about this incident.
These findings were reviewed with the current DON at that time. She agreed that the email indicated that the facility was aware of the allegation of abuse prior to the date it was reported to the State Agency on 9/5/23.
She was unable to provide any additional information regarding the family's initial report to the facility staff prior to 9/5/23 as indicated in the email. The facility failed to report the incident and initiate an investigation within 2 hours of when the allegation of abuse was initially reported by Resident #1's family member.
3. Review of another FRI #MD00200889 on 6/13/24 at 1:00 PM revealed that on 12/22/23 Staff #24 the former Administrator received a text message at 10:47 AM from Resident #1's family member reporting an allegation of abuse. Per the facility's documentation, he did not read the message until 12:29 PM on 12/22/23. The facility sent the initial report of the allegation to the State Agency on 12/22/23 at 6:18 PM. It was not reported within 2 hours after the allegation was made.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0609 4. FRI #MD00204370 involving Resident #1 was reviewed on 6/17/24 at 8:00 AM. The facility's initial report indicated that the DON and Unit Manager reported to Administrator (#24) on 4/4/24 at approximately 5:30 Level of Harm - Minimal harm or AM that the police had been contacted by a complainant regarding an incident of abuse that allegedly potential for actual harm occurred on 2/13/24. The report also indicated that the incident was reported to the clinical management staff and to Resident #1's representative on 2/14/24. The investigation report revealed that the Unit Manager Residents Affected - Some (#38) performed an interview with Resident #1 on 2/14/24 at approximately 10 AM, regarding the incident. In
an interview on 6/17/24 at 4:16 PM the surveyor reviewed the report with Unit Manager (#38) who confirmed that the incident was not reported to the State Agency on 2/14/24 but on 4/4/24 almost 2 months later. She stated, we investigated it then reported it. She confirmed that she did not notify the State Agency and indicated that the Administrator (#24) was notified by her the same day. She stated, Once I report it to the administration, I take my hands off, they do the reporting and investigation. She confirmed that 911 was not called on 2/14/24.
5. The facility's investigation documentation related to Facility Reported Incident (FRI) #MD00205514 was reviewed on 6/11/24 at 10:15 AM. The report indicated that on 5/8/24 at approximately 11:00 AM, Resident #1 reported that a Geriatric Nursing Assistant (GNA) grabbed his/her arm and left a red mark. The facility reported an allegation of abuse to the State Agency within 2 hours and conducted an investigation. Per the Follow-up Investigation Report Form, the final report was sent to the State Agency on 5/16/24. This was more than 5 business days after the alleged incident.
The Administrator and Director of Nursing were made aware of these findings on 6/18/24 at 9:04 AM.
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6. The facility staff failed to report an allegation of abuse to OHCQ (Office of Health Care Quality) for Resident #2.
During interview with Resident #2's Responsible Party (RP) on 6/12/24 at 11:00 AM, the RP stated he/she felt on 3/17/24 LPN #6 was rough with Resident #2 when he/she walked into the Resident's room on 3/17/24.
The RP stated he/she told LPN #6 to stop abusing Resident #2. The RP stated he/she notified the former Administrator on 3/17/24 at 10:25 AM via text of his/her concern and the former Administrator responded back on 3/17/24 at 11:36 AM he was looking into it now.
During interview with Director of Nursing (DON) on 6/12/24 at 9:42 AM, the DON stated the only Facility Reported Incident for Resident #2 in 2024 was from 4/12/24.
During interview with the DON on 6/13/24 at 8:15 AM, the Surveyor reviewed Resident #2's RP's concerns
on 3/17/24 and asked what the facility did at the time. The DON stated she would get back to me.
On 6/13/24 at 8:50 AM, the DON provided the Surveyor the facility's investigation of the 3/17/24 incident with Resident #2 including staff and resident interviews. The DON was asked at that time why it was not reported to OHCQ. The DON stated because in our investigation we found it not to be abuse.
During interview with the former Administrator on 6/13/24 at 10:39 AM, the Surveyor reviewed the incident and asked why he did not report the incident on 3/17/24 to OHCQ and he stated because we found it not to be abuse.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0609 Interview with the DON on 6/13/24 at 8:50 AM confirmed the facility staff failed to report to OHCQ on 3/17/24
an allegation of abuse for Resident #2. Level of Harm - Minimal harm or potential for actual harm 7. The facility staff failed to report an allegation of abuse for Resident #7 within 2 hours of the allegation on 1/23/23. Residents Affected - Some
Review of Resident #7's medical record on 6/11/24 revealed the Resident was admitted to the facility on [DATE REDACTED] and was assessed to be alert and oriented.
Review of a facility reported incident for Resident #7 revealed on 1/23/23 at approximately 6:00 PM, Resident #7 called the police to report GNA (geriatric nursing assistant) #36 held his/her wrist while removing his/her dinner tray.
Further review of the facility reported incident revealed the former Administrator did not report the incident to OHCQ until 1/24/23 at 5:02 PM.
Interview of the DON on 6/14/24 at 1:08 PM confirmed the facility staff did not report Resident #7's allegation of abuse on 1/23/23 until 1/24/23.
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8. Facility reported incident #MD00164917 related to an allegation of abuse involving Resident #62 and a facility employee was reviewed on 6/12/24 at 11:50 AM. The incident was documented as occurring on 3/10/21. According to the facility investigation report documentation that was sent to the Office of health care quality, the 5 day follow up was not received until 3/17/21.
This documentation was confirmed with the current facility DON and Administrator on 6/12/24 at 1:36 PM.
9. A. Review of the facility reported incident #MD00204392 on 6/11/24 at 9:07 AM revealed an allegation of abuse that occurred on the early morning of 4/5/24 with the night shift staff that worked from 4/4/24 into 4/5/24. The nurse failed to report the allegation to the supervisor timely.
According to the facility reported incident, Resident #3 reported to the night shift nurse LPN, staff # 6, about
an allegation of inappropriate behavior and interaction between him/her and the GNA providing activities of daily living (ADL) care at around 2:00 AM. This information was not passed on to any supervisor and GNA #3 continued to work her entire shift.
Resident #3 reported the interaction again to the charge nurse on the day shift and Resident #3 was assessed for injuries. The resident was found to have an injured thumb requiring pain medication 3 times a day for the next 5 days.
B. Further, according to the facility investigation, the facility did not complete the interviews and investigation for the abuse incident until 7 days on 4/12/24 not the required 5 days.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 Respond appropriately to all alleged violations.
Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31982 potential for actual harm Based on review of facility documentation and interview with staff it was determined the facility staff failed to Residents Affected - Some investigate, prevent, and correct alleged abuse violations. This was evident for 6 of 27 abuse allegations reviewed related to Residents (#1, #24, #29, #3, #61 and #17).
The findings include:
1. Facility Reported Incident (FRI) #MD00186593 was reviewed on 6/11/24 at 12:50 PM. The report alleged that on 12/14/22 Staff #37, a Geriatric Nursing Assistant (GNA) photographed Resident #1 while he/she was sitting on the toilet. The facility's investigative documentation included a typed statement from Staff #37. It did not include the date and time the statement was written nor when the events described in the statement took place. The statement was not signed by the person providing the statement to indicate it was their statement. The facility's report indicated that the incident occurred on 12/9/22 at 11:45 AM and the police were notified on 12/9/22 at 11:45 AM. However, review of GNA #37's time punch record on 6/12/24 at 11:46 AM revealed that GNA #37 worked from 6:54 AM - 3:00 PM on 12/9/22. She was not removed from duty at
the time of the report and was allowed to work the entire shift. There was no evidence that GNA #37 received education related to resident abuse after the incident.
2. The facility's investigation documentation for Facility Reported Incident (FRI) #MD00196546 was reviewed
on 6/13/24 at 11:13 AM. The report indicated that the Director of Nursing (DON) received an email from Resident #1's family member on 9/5/23 alleging that a staff member was abusive toward Resident #1. In the email, the family member described a woman with yellow hair as the perpetrator. There was no indication that the facility identified or attempted to identify the woman with yellow hair during their investigation. A statement from Staff #32, a night shift nursing supervisor indicated that a Certified Medication Aide (CMA) interacted with Resident #1 during the night in question. However, he did not identify the CMA and the investigation did not include a statement from a CMA. During an interview on 6/12/24 at approximately 11:00 AM the Director of Nursing was asked to identify the CMA who was working the night of 8/30/23. She indicated that the facility had no CMA's working night shift. The facility did not attempt to identify the person that Staff #32 was identifying as the CMA, during their investigation or obtain a potential witness statement from that person.
Abuse Prevention Measure Interviews were documented with additional staff. Staff #33 a GNA answered yes to the question: Have you recently witnessed a resident being abused, neglected or treated rudely or harshly? There was no explanation or details documented in the space provided. There was no indication that the Administrator reviewed the response and further investigated.
The facility's documentation included sign in sheets for Abuse education dated 9/5/23. The sheets included signatures of 29 staff. However there was no evidence that education was provided to Staff #32, or GNA's #34 and #35 who were the staff working with Resident #1 on the night of the alleged incident. Review of the time punch cards for the accused GNA #34 revealed she was not suspended until 9/5/23 and had worked 11pm - 7am on 9/1/23.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 3. FRI #MD00204370 involving Resident #1 was reviewed on 6/17/24 at 8:00 AM. The facility's initial report revealed the DON and Unit Manager reported to Administrator (#24) on 4/4/24 at approximately 5:30 AM that Level of Harm - Minimal harm or the police were contacted by a complainant regarding an incident of abuse that occurred on 2/13/24. The potential for actual harm report also indicated that the incident was reported to the clinical management staff and to Resident #1's representative on 2/14/24. The investigation report indicated that the Unit Manager (#38) performed an Residents Affected - Some interview with Resident #1 on 2/14/24 at approximately 10 AM, regarding the incident. In an interview on 6/17/24 at 4:16 PM the surveyor reviewed the report with Unit Manager (#38). She confirmed that the incident was not reported to the State Agency on 2/14/24 when it occurred, but on 4/5/24 almost 2 months later. She stated, we investigated it then reported it.
The facility report revealed that in an investigation interview the night shift supervisor (#32) indicated that Resident #1 did not inform him of any alleged abuse or mistreatment by GNA #35. Interviews with other staff who worked during the 11pm - 7 am shift on 2/13/24 indicated that they did not know of any concerns. However, Unit Manager #38, the Administrator #24 as well as the clinical management staff were aware of
the resident's allegation but failed to report and immediately investigate the allegation of abuse. An investigation was not conducted until 4/5/24.
The facility's report revealed GNA #35, the alleged perpetrator, was relocated to other room assignments and taken off Resident #1's assignment effective 2/13/24. GNA #35 was suspended for 3 days pending the investigation outcome after 4/5/24. The facility failed to remove GNA (#35) from duty at the time of the alleged incident. No documentation was found to indicate that GNA (#35) received education related to abuse after the allegation.
The DON was made aware of these findings on 6/17/24 at 2:00 PM. She was asked to provide evidence that
the staff involved in the above allegations of abuse were provided with education related to the allegations.
On 6/17/24 at 2:50 PM the DON returned with the ADON (Assistant Director of Nursing). The ADON indicated that she was not able to find documentation that education was provided to the staff accused of abuse of Resident #1. She indicated that they were interviewed regarding the incidents, statements were written, and they were sent off duty, however, there was no evidence that they were provided with education.
The Administrator and Director of Nursing were made aware of these findings on 6/18/24 at 9:04 AM.
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4. On 6/11/24 at 10:38 AM a review of the facility's investigation file for the facility reported incident #MD00186435 revealed a self-report form that documented on 12/5/22 at 2:25 PM the resident reported that Housekeeper #20 had pushed him/her which resulted in a fall.
Interviews were conducted with the witnesses, by the previous Administrator #24, on 12/7/22 however the
interview information was confined to 2- 3 questions. The interview with Housekeeper #20 revealed the 3 questions were: 1) where was the resident standing when you approached them, 2) How did the resident fall, and 3) Did you ask the resident not to enter the housekeeping closet? The facility failed to obtain a written, narrative statement from the housekeeper to allow him to put in his own words what had happened.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 A review of the interview conducted with Unit Clerk (UC) #26 on 12/6/22, by the previous Administrator #24 revealed her questions were: 1) What did you witness in regard to [Resident #29] fall incident yesterday and Level of Harm - Minimal harm or 2) Did you hear loud voices prior to the fall? The facility failed to obtain a written statement from the UC to potential for actual harm allow her to fully explain what she had witnessed about the incident.
Residents Affected - Some A review of the staff statements obtained from Registered Nurse (RN) #22, and RN #21, revealed that RN #22 stated the resident was laying on their back in the hallway and Resident #21 stated the resident was sitting in the hallway. Facility staff failed to reconcile these differences in their investigation.
RN #22 wrote in his statement that he when he saw Resident #29 laying on the floor, he went to them to assess and assist them off the floor. He did not write that the resident said anything to him at the time but stated that he asked Housekeeper #20 if he had pushed the resident to which the housekeeper replied he had pushed the resident because they were attempting to come into the housekeeping closet. The surveyor was unable to interview RN #20 because the facility had no contact information available, therefore it was uncertain if he was the staff member that Resident #29 had reported they were pushed by the housekeeper as stated on the self-report form.
Further review of facility's investigation file revealed that they failed to obtain statements or interview other staff who may have had knowledge of how this housekeeper interacted with other residents. The housekeeper's supervisor was not interviewed.
A medical record review for Resident #29 on 6/11/24 at 11:34 AM revealed a discharge summary from the local hospital dated 12/3/22 that documented the resident had open heart surgery on 11/18/22. The resident was sent to the facility for rehabilitation services. Review of the therapy notes for an evaluation conducted on 12/5/22 revealed therapy had not ambulated the resident due to safety concerns.
An interview conducted over the phone with the previous Administrator #24 on 6/13/24 at 10:12 AM revealed that he had not determined through his investigation that Housekeeper #20 was abusive towards Resident #29. However, when asked if the actions of the employee were willful without intention to harm the resident was considered abuse and if it was abusive for the housekeeper to go about his duties without assisting the resident after they fell , he stated that he could see where it could be perceived that it was abuse. There was no evidence that housekeeping staff were educated on what to do if a resident was attempting to enter a housekeeping closet to prevent further incidents of abuse.
The concerns were reviewed with the current Administrator and Director of Nursing on 6/13/24 at 12:34 PM.
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5. Review of the facility reported incident (FRI) and investigation packet for #MD00204392 on 6/11/24 at 7:39 AM revealed an allegation of abuse between a GNA #3 and Resident #3 occurring at approximately 2:00 AM
on 4/5/24.
The staffing schedule for 4/5/24 was in the packet, the schedule form 4/4/24 into 4/5/24 was not available.
This surveyor asked for the schedule from that time on 6/11/24 at 9:07 AM from the DON.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 Continued review of the facility investigation packet reviewed on 6/11/24 at 9:10 AM, the staff from the day shift of 4/5/24 was interviewed regarding the incident and allegation from the nightshift of 4/4/24 into 4/5/24. Level of Harm - Minimal harm or However, not all the staff from the 4/4/24-4/5/24 shift were interviewed. potential for actual harm Additionally, 3 of the staff that were interviewed were not interviewed until 7 days after the incident. The DON Residents Affected - Some was asked about the statements in the packet as they were dated 4/12/24 and there was no other signature noting who was conducting the interview. The DON stated that the 'the date is just when the administrator typed up the interview.' This surveyor tried to confirm who did the interview, when it was done and the time. However, she was unable to confirm when it occurred, but stated that it was the previous Administrator that had conducted the interviews
The concern that the facility failed to interview all the potential employees that were present at the time of the allegation and further document on the interviews who completed them, and the actual date and time of the
interview was reviewed on 6/11/24 at 10:10 AM.
6. On entrance to the facility on [DATE REDACTED] a list of facility reported incidents was emailed to the Administrator and requested for review, including for Resident #61.
The surveyor began reviewing the facility reported incident #MD00165609 on 6/11/24 at approximately 11 AM revealed an allegation from Resident #61 alleging s/he was abused from 'a gang of hooligans.'
The investigation into this allegation was requested again on 6/11/24. A small packet was provided that only contained progress notes and psychiatric notes from the time of the event.
There were no interviews or other investigation details.
This concern was reviewed with the DON on 6/12/24 at 1:36 PM and she stated that she was aware since
the incident had occurred in 2021 and they did not have the investigation file.
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7. Review of Resident #17's facility reported incident (MD 00195075) on 6/10/24 at 11:30am revealed the resident alleged that facility nursing staff grabbed the resident's legs roughly after the resident complained of pain from an arthritic hip. The resident also alleged facility nursing staff slapped the resident in the face when
the resident asked nursing staff to stop treating him/her roughly.
Review of the facility's investigation on 6/10/24 at 11:00 revealed that Resident #17 made the abuse allegation on 8/2/23. The facility report was missing interviews from nursing staff scheduled on the day of the allegation.
Surveyor interview with the Director of Nursing (DON) on 6/11/24 at 9:00am revealed that the facility was unable to locate the missing staff interviews and he/she was unable to confirm that staff interviews were conducted when the abuse allegations were being investigated.
The surveyor expressed concerns that the facility investigation of the allegation of abuse toward Resident #17 was not a thorough investigation on 6/11/24 at 9:30am.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Level of Harm - Minimal harm or potential for actual harm 30428
Residents Affected - Few Based on the review of a complaint, staff and resident interview and medical record review, it was determined that the facility failed to adequately prepare a resident for discharge. This was evident during the
review of 1 of 2 complaints regarding discharges. (Resident #5)
The findings include:
Review of the complaint #MD00203025 on 6/10/24 at 9:45 AM revealed concerns regarding his/her discharge planning and preparation as well as the actual day s/he left the facility and not receiving all their personal property.
A closer review on 6/10/24 of the discharge that occurred on 2/23/24 and the completed paperwork revealed that Resident #5 had not signed any discharge paperwork, including the discharge instructions/post discharge plan review or the resident property list.
The facility DON was interviewed on 6/10/24 at 11:49 AM. The facility process on discharge was reviewed.
She stated that the staff are to review the discharge planning and have the resident sign it and then it is scanned into the computer. Additionally, this is the process for the resident property list. Neither one of these processes were competed for Resident #5.
LPN staff #5 was interviewed on 6/10/24 at 1:47 PM regarding the discharge process. He reiterated the same process as the DON had just reviewed. The discharge that occurred with Resident #5 was reviewed as well as the paperwork that he had completed on 2/23/24 according to the electronic health record. He stated that he had no recollection of the discharge. He further could not explain why the paperwork was not completed as per the facility process.
On 6/12/24 at 1:36 PM the DON and NHA were notified of the identified concerns of discharge preparations secondary to the complaint and further identified lack of documentation on behalf of the facility and failure of following of the facility process related to discharge planning and preparation was reviewed.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0641 Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm or 31982 potential for actual harm Based on medical record review and interview with staff it was determined the facility staff failed to Residents Affected - Some accurately complete resident assessments reflective of the resident's status. This was evident for 5 of the last 5 assessments for 1 (Resident #1) of 65 resident's reviewed for during the survey.
The findings include:
The MDS (Minimum Data Set) is part of the Resident Assessment Instrument that was Federally mandated
in legislation passed in 1986. The MDS is a set of assessment screening items employed as part of a standardized, reproducible, and comprehensive assessment process that ensures each resident's individual needs are identified, that care is planned based on those individualized needs, and that the care is provided as planned to meet the needs of each resident.
The Brief Interview for Mental Status (BIMS) is a 15-point cognitive screening test that evaluates memory and orientation. 0-7 points: Severe cognitive impairment, 8-12 points: Moderate cognitive impairment and 13-15: Intact cognition.
A PHQ (Patient Health Questionnaire) is a nine-item questionnaire that can be used to assess the severity of depression.
A brief interview was conducted on 10/11/24 at 10:39 AM with Resident #1. He/She was able to communicate verbally however he/she had difficulty forming words clearly and communicated his/her thoughts and questions to the surveyor by writing on a piece of paper.
Resident #1's record was reviewed on 6/12/24 at 2:05 PM. The most recent MDS assessment was a quarterly assessment with an ARD (assessment reference date) 4/24/24.
Section C Cognitive Patterns C0100 asked the question: Should Brief Interview for Mental Status (BIMS) (C0200-0500) be Conducted? A dash (-) was marked in the space provided. It was not coded to indicate 0. No or 1. Yes as indicated in the instructions. Staff Assessment for Mental Status (C0600-C1000) also contained dashes. Resident #1's cognitive pattern was not assessed.
Section D Mood D0100 Should Resident Mood Interview be Conducted? Was coded 1. Yes - Continue to D0150, Resident Mood Interview (PHQ-2 to 9). The spaces provided for the mood interview answers all contained a dash (-). They were not answered 0. (No), 1. (Yes) or 9. (No response), as indicated in the instructions. Staff Assessment of Resident Mood (D0500) was not completed. Resident #1 was not assessed for depression.
Review of section's C and D for the quarterly MDS assessments with ARD's 3/1/24, 10/13/23, and 4/12/23 and the most recent Annual MDS assessment with an ARD of 7/13/23 also contained dashes or were left blank. They were not coded as per the instructions. The surveyor was unable to find that Resident #1's Cognitive Status and Mood were assessed quarterly for the past year.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0641 An interview was conducted on 6/12/24 at 12:55 PM with Staff #23 Registered Nurse/MDS Supervisor. She indicated that she has worked in the facility since 8/2017 and was familiar with Resident #1. She was asked Level of Harm - Minimal harm or why Section C and D were not completed in Resident #1's MDS assessments. She indicated that lately potential for actual harm Resident #1's BIMS has not been done. She then indicated that the resident and family have requested that no assessments be done and added also PHQ-9. She indicated that a staff assessment could be done but Residents Affected - Some the other MDS nurse attempted it in the past and Resident #1's family had a fit. She stated I went to my top people - corporate management. She was asked if the requirement for the MDS assessments was discussed with the family. She indicated yes, and that they did not provide rationale for refusal. She indicated that Resident #1 had a Plan of Care for refusing assessments and laboratory tests.
Further review of Resident #1's medical record on 6/13/24 at 8:00 AM failed to reveal a plan of care addressing assessments or the resident/family refusal.
Review of the RAI (Resident Assessment Interview) Manual Version 3.0 instructions, revealed specific instructions for properly coding MDS Sections C and D when the resident refuses to answer. It included the proper codes to use when the resident refused and guidance for the Assessor to proceed to item D0700, Social Isolation in the case of resident refusal or unwillingness to participate.
These instructions were not followed by the facility staff.
The Administrator and Director of Nursing were made aware of these findings on 6/18/24 at 9:04 AM.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm 30428
Residents Affected - Few Based on medical record review and interview with facility staff, it was determined that the facility failed to implement a care plan related to a resident's primary diagnosis and therefore implement a plan of care related to that diagnosis. This was evident for 1 of 65 residents (#43) reviewed during a complaint survey.
The MDS (Minimum Data Set) is a complete assessment of the resident which provides the facility information necessary to develop a plan of care, provide the appropriate care and services to the resident, and to modify the care plan based on the resident's status.
The findings include:
Review of the medical record for Resident #43 on 6/14/24 at 10:59 AM revealed admitting diagnosis for surgical aftercare following surgery on the circulatory system. Resident #43 had arrived at the facility after s/he went home postoperatively from right lower extremity surgery on the circulatory system. At home s/he developed cellulitis and returned to the hospital for antibiotics and required further rehabilitation services at
this nursing care facility. On admission to the nursing home, s/he was noted by the wound care nurse practitioner with 3 surgical incisions on the right leg; the groin, the medial and the anterior areas of the right leg, all incisions requiring wound care and treatment daily.
A concurrent review of the residents' care plan failed to reveal a care plan in place related to wound or skin care treatment needed for the identified areas. A care plan was identified on 6/14/24 related to cellulitis and antibiotic use related only to the infection that the resident developed post-operatively. However, there was nothing in the care plan related to Resident #43's main diagnosis of surgical wound care.
The 2/8/22 MDS section M (skin conditions) identified Resident #43 as having surgical wounds and the care area assessment (CAA) triggered for care plans to be initiated related to pressure ulcer/injury. However, the care plan that was developed only referenced the residents' 'risk' for skin breakdown related to immobility and incontinence.
As there was no staff present in the facility at this time that were present at the time of the residents admission that would have been responsible for the development of the care plan, the identified concerns were reviewed with the current DON and current Nursing Home Administrator on 6/14/24 at approximately 1:00 PM and again on exit on 6/18/24 after no further information was provided to the survey team.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0661 Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34484
Residents Affected - Few Based on medical record review and staff interview it was determined that the facility failed to ensure that residents had a discharge summary and it was complete and accurate (Resident #17, #25, #36 and #54).
This was evident for 4 of 65 residents reviewed during a complaint survey.
The findings include:
1. Review of Resident #25's medical record on 6/17/24 revealed the Resident was admitted to the facility to 2/28/23 from the hospital and went to a surgery appointment on 5/19/24 at 4:15 AM.
Further review of the medical record revealed the Resident did not return to the facility following the appointment.
Further review of the medical record revealed no final summary of the resident's status at the time of discharge.
Interview with the Director of Nursing on 6/17/24 at 2:10 PM confirmed the facility staff failed to document a discharge summary in Resident #25's medical record.
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2. Review of resident #21's medical record on 6/10/24 at 12:36pm revealed no evidence of a discharge summary after the resident was transferred from the facility to a local hospital on 9/2/23 and failed to return to the facility after the transfer.
Interview with the Director of Nursing (DON) on 6/10/24 at 1:36pm confirmed that the resident did not return to the facility after transfer to a local hospital. DON also confirmed that the facility was unable to locate a provider discharge note. The surveyor expressed concern that the facility failed to provide a provider discharge note after the resident's discharge from the facility.
3. Review of resident #36's medical record on 6/17/24 at 9:30pm revealed no evidence of a discharge summary after the resident was transferred from the facility to a local hospital on 9/17/22 and failed to return to the facility after the transfer.
Interview with the Director of Nursing (DON) on 6/17/24 at 10:52am confirmed that the resident did not return to the facility after transfer to a local hospital. DON also confirmed that the facility was unable to locate a provider discharge note. The surveyor expressed concern that the facility failed to provide a provider discharge note after the resident's discharge from the facility.
4. Review of resident #54's medical record on 6/17/24 at 9:00am revealed no evidence of a discharge summary after the resident discharged from the facility on 4/14/22.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0661 Interview with the Director of Nursing (DON) on 6/17/24 at 10:30am confirmed that the resident discharged
on [DATE REDACTED] and the facility was unable to locate a provider discharge note. The surveyor expressed concern Level of Harm - Minimal harm or that the facility failed to provide a provider discharge note after the resident's discharge from the facility. potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or 30428 potential for actual harm Based on the review of a complaint, medical record review and interview with staff, it was determined that Residents Affected - Some staff failed to provide all treatment and care to residents in accordance with professional standards of practice by failing to follow practitioner orders and established care plans. This was evident for 4 of 65 (#43, #1, #25 and #20) residents reviewed during a complaint survey.
A care plan is a guide that addresses the unique needs of each resident. It is used to plan, assess and evaluate the effectiveness of the resident's care.
The findings include:
1. Review of the medical record for Resident #43 on 6/14/24 at 10:59 AM revealed admitting diagnosis for surgical aftercare following surgery on the circulatory system. Resident #43 had arrived at the facility after a short stay at home with 3 areas, the groin, the medial and the anterior areas of the right leg all noted as surgical incisions requiring wound care and treatment by the wound care nurse practitioner on admission.
A review of the physician orders failed to reveal orders in place for the treatment of 2 of the 3 wounds, only wound care for the groin wound was addressed.
A review on 6/14/24 of the physician history and physical documented as completed on 2/5/22, also failed to reveal any review or identification of the surgical wounds or plan for the care of the wounds.
The hospital discharge summary, also reviewed at this time, did not have care instructions for the surgical wounds; however, the wound nurse practitioner saw the resident on admission on 2/7/22 and had recommendation to apply dry dressing daily and clean with normal saline on all the identified wounds. According to the medication and treatment administration record the only orders in place were for wound care for the groin wound and to 'monitor the surgical site (staples) to the right lateral and medial lower leg every shift.'
This identified concern was reviewed with the DON on 6/14/24 at approximately 1:00 PM and again during exit on 6/18/24 after no further documentation related to wound care treatment was provided.
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2. The facility staff failed to assess and provide care to a scalp wound for Resident #25.
Review of Resident #25's medical record on 6/17/24 revealed the Resident was admitted to the facility to 2/28/23 following craniectomy surgery. A craniectomy is a major brain surgery that involves removing part of
the skull to relieve pressure on the brain.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0684 Review of the Neurosurgeon's progress notes from a follow up appointment on 4/4/23 revealed the Neurosurgeon documented, I am concerned about his/her scalp healing. Discussed wound with wound care, Level of Harm - Minimal harm or Recommendations are to apply Medihoney daily, and cover with dressing. Medihoney needs to be applied at potential for actual harm a minimum every three days, and covered.
Residents Affected - Some Further review of Resident #25's medical record revealed no assessment of the Resident's post surgical scalp wound on admission to the facility and no treatment of the wound until 4/6/23. The wound was not documented it was assessed by the wound team until 4/7/23.
Interview with the Director of Nursing on 6/17/24 at 2:10 PM confirmed the facility staff failed to assess Resident #25's scalp wound on admission and provide treatment until 4/6/23.
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3. Review of a Facility Reported Incident (FRI) on 6/13/24 at 1:00 PM revealed that Resident #1 alleged that that a Phlebotomist (Laboratory technician) and a nurse held his/her arms and legs during an attempted blood draw on 12/21/23 at approximately 6:30 PM. The facility's investigative documentation revealed that in response to this allegation, on 12/28/23 staff were educated to have 2 people present at all times when providing any care or procedures to Resident #1. Resident #1's medical record revealed a verbal order written by a Nurse Practitioner (NP) on 12/29/23 at 15:02 for Resident is a two person assist with ADL's (Activities of Daily Living), Transfers, and any procedures every shift.
A care plan intervention: Answer resident's call light and enter room with another person was initiated on 1/22/24 to Resident #1's plan of care for behaviors.
A plan of care was initiated on 5/15/24 for: (Resident #1) will have 2 Caregivers/2 Nurses at bedside at all time during ADL Care and when Caring for the resident needs. It was initiated on 5/15/24. The surveyor was unable to find how the NP's order was consistently communicated to all staff and providers that provide care for Resident #1 between 12/29/23 and when the plan of care was developed on 5/15/24.
Review of another FRI on 6/17/24 at 9:36 AM revealed that Resident #1 made an allegation on 6/10/24 at 7:20 PM that he/she was slapped during the prior night shift by a GNA (#39).
A statement from GNA #39 indicated that in the evening on 6/9/24 she provided ADL care and left the resident in bed asleep. She indicated that she returned to the room at approximately 1:30 AM on 6/10/24 with a nurse (#40) to assist the resident to the bathroom. When they returned to assist him/her back to bed, GNA(#39) left the room at Resident #1's request and the nurse (#40) assisted the resident back to bed from
the bathroom.
A statement from the Registered Nurse (RN) (#40) indicated that he and the GNA (#39) assisted the resident to the bathroom on 6/9/24. He indicated that the GNA was in the bathroom with Resident #1 and after about 2 minutes, the GNA (#39) opened the door and indicated (Resident #1) needs you. The resident then stated to him I don't want to work with (GNA#39) anymore. When Nurse #40 asked about any specific reasons the resident did not provide a reason. The statements by GNA #39 and RN #40 indicated that neither staff member ensured that 2 staff were present when care was provided for Resident #1 during the night of 6/9/24 as per Resident #1's Plan of Care and the NP order.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0684 On 6/17/24 at 2:00 PM the DON was asked to provide documentation of where the NP order written on 12/29/23 for 2 person assist was transcribed/communicated to staff. None was provided. Level of Harm - Minimal harm or potential for actual harm An interview was conducted on 6/17/24 2:50 PM with the Director of Nursing (DON) and Assistant Director of Nursing (ADON). Residents Affected - Some
The DON indicated that an order for 2 person assist with ADL's, transfers, and any procedures every shift is
a nursing order not a physicians order. She was made aware that on 12/29/23 15:02, a NP provided a telephone order for 2 staff to assist. She was asked how this order on 12/29/23 would have been transcribed or otherwise communicated to ensure that it was consistently implemented by all staff. She explained that it should not have been ordered. She added that the information would be passed on verbally during the change of shift report.
She was made aware that it is on the resident's current plan of care (initiated 5/15/24 - 2 caregivers/2 nurses at bedside at all time during ADL Care and when Caring for the resident needs.) However, it was not added until 5/15/24. She was made aware that statements the facility obtained from staff during abuse investigations indicated that staff were providing care for the resident alone. She was made aware of the most recent incident in the early morning of 6/10/24 in which GNA #39 assisted the resident in the bathroom alone. She indicated that the Nurse that was on duty (RN #40) was a male, so the GNA needed to provide care alone. She was asked if the GNA soul have gotten another female staff for assistance. She replied that if another female staff is not available, then staff are to provide care to the resident alone to maintain dignity.
An interview was conducted with Staff #32 a Registered Nurse on 6/18/24 at 6:57 AM. He confirmed there should be 2 staff at all times when caring for Resident #1 and that it was implemented about 2 months ago and there was a lot of he said/she said going on.
During an interview on 6/18/24 at 7:08 AM GNA (#35) confirmed that there should be 2 people at all times when caring for Resident #1 and indicated the intervention was started about 6 months prior. She stated we always go with 2 because he/she always complains. 2 people to always have a witness. The Administrator and Director of Nursing were made aware of these findings on 6/18/24 at 9:04 AM.
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4. On 6/11/24 at 12:42 PM, a medical record review was conducted for Resident # 20. Resident # 20 has a diagnosis of Congestive Heart failure, and other diagnosis.
There were multiple orders for obtaining weights for Resident # 20. On 5/4/23 order stated to weigh resident every day shift for 7 days. On 5/4/23 there was a second order to weigh resident every day shift every Tuesday and on 5/5/23 there was a third order to weigh Resident # 20 every day. There were no weights taken on 12 dates in 05/23 and 18 dates in 06/23, as well as 3 dates in 07/23.
The Director of Nursing (DON) was interviewed on June 11, 2024, regarding multiple orders for obtaining weights. The DON stated the orders for 5/4/23 should have been discontinued or clarified with the doctor regarding frequency of weights for Resident # 20.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or 30428 potential for actual harm Based on the review of a complaint, medical record review and interview with staff, it was determined that Residents Affected - Few the facility failed to implement wound care orders for a resident with a stage 3 pressure ulcer. This was evident during the review of 2 of 5 residents (#40 and #37) reviewed for wounds during a complaint survey
The findings include:
1. Review of the complaint #MD00175703 on 6/10/24 at 11:25 revealed concerns related to the treatment of Resident #40's wounds that were identified as a stage 3 sacral ulcer.
Further review at this time of Resident #40's medical record revealed that s/he had a re-hospitalization
during their stay. Upon readmission to the facility, there were no wound care orders reinstated for the treatment of the sacral stage 3 ulcer until Resident #40 was seen by the wound care nurse practitioner 3 days later on 2/25/22. Prior to discharge the wound care regimen consisted of treatment 3 times a day.
A review of Resident #40's physician orders and medication and treatment administration record confirmed that there were no orders or treatments implemented during the time frame of 2/22/22-2/25/22.
This identified concern was reviewed with the facility DON on 6/12/24 at 1:36 PM along with the facility Administrator.
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2. On 6/12/24 at 10:13 AM a medical record review was conducted for Resident # 37. Resident # 37 has multiple wounds on both legs and is seen by the wound care team weekly. On 6/18/22, an order was given to apply kerlix and ace bandage daily to left lower leg from 6/18/22 to 7/17/22. On 6/27/22 kerlix and ace bandage were not applied after wound care visit.
On 06/12/2024 an interview was completed with the Director of Nursing (DON), The DON offered no reason why the wound care had not been completed.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 18819
Residents Affected - Few Based on complaint, reviews of a closed medical record, and staff interviews, it was determined that the 1. facility staff failed to follow a resident's fall prevention care plan to ensure all nursing interventions were implemented. Resident #8 did not have the call light within reach and tried to walk to the restroom without assistance and fell . This was evident for 1 (Resident #8) of 65 residents reviewed during a complaint survey and 2. the facility failed to ensure that staff were using a mechanical lift to transfer residents based on the manufacturer's instructions to ensure resident's safety. This was evident for 1 of 1 observation of a resident transfer in a mechanical lift.
The findings include:
1. A review of complaint MD00198899 on 06/11/24 revealed an allegation that Resident #8 had fallen and was not assessed or treated.
A review of the facility Falls Management Program policy, on 06/11/24, listed a procedure that included but not limited to: Prevention, a Fall Risk Tool will be completed upon admission, readmission, quarterly and as needed, Discuss fall risks and interventions with patient and the responsible party, Incorporate any identified interventions into the care plan, refer the patient to PT/OT for screening, evaluation, and treatment, consult with the maintenance department for any necessary adaptations. Under Fall Occurrence, #1 - The nurse will notify the resident's provider, responsible party, and/or EMS if indicated, as well as the supervisor/administrative personnel as appropriate.
A review of Resident #8's closed medical record on 06/11/24 at 11 AM revealed that Resident #8 had been admitted to the facility on [DATE REDACTED] for rehab after being treated at the hospital for a fall, dementia, normal pressure hydrocephalus, upper GI bleed and thrombocytopenia. On 10/07/23 at 2:15 AM, Resident #8 was observed on the floor and was unable to describe to the nursing staff what had happened. Resident #8 denied pain or hitting his/her head. On the morning of 10/09/23 at 11:39 AM, Resident #8's wife noted Resident #8 had left sided weakness. Resident #8 was seen by one of the facility physicians and an order was created to send Resident #8 to the hospital to evaluate a new left facial droop and left upper extremity weakness. The goal was to obtain a cat scan of the head to rule out a blocked brain shunt versus a transient ischemic attack or a stroke. Resident #8 was subsequently readmitted to the facility on [DATE REDACTED]. Resident #8 was treated for generalized weakness and possible pneumonia
A review of Resident #8's fall prevention care plan, dated 10/08/23, on 06/13/24 revealed 2 nursing goals for preventing Resident #8 from falling. The first fall prevention goal was that Resident #8 will be free of minor injury. The second fall prevention goal was that Resident #8 will not sustain a serious injury. Nursing interventions included: be sure the resident's call bell is within reach and encourage the resident to use it for assistance, staff to conduct frequent checks to ensure safety.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0689 On 10/24/23 at 3:43 PM, Resident #8 was observed again on the floor by staff. When Resident #8 was asked by the nursing staff what had happened, Resident #8 stated that s/he was trying to walk to the Level of Harm - Minimal harm or bathroom and tripped. A review of Resident #8's post fall review, dated 10/25/23 at 9:08 AM, staff member potential for actual harm #5 completed all sections of the assessment and then signed the assessment. In an interview with staff member #5 on 06/13/24 at 9:23 AM, staff member #5 confirmed completing Resident #8's post fall Residents Affected - Few assessment for Resident #8's 10/24/23 fall. The nurse surveyor then asked staff member #5 to review section C, Fall, question d. Question d asked the nurse was the call light within reach? Staff member #5 documented No. Staff member #8 stated that he could not recall Resident #8's 10/24/23 fall and had to go with what s/he documented at the time.
In an interview with Resident #8's attending physician on 06/13/24 at 11:15 AM, Resident #8's attending physician stated that s/he was not immediately notified by the nursing staff of Resident #8's fall on 10/24/23. Resident #8's attending physician stated that s/he was made aware of Resident #8's 10/24/23 fall by Resident #8's family member on the morning of 10/25/23. Resident #8's attending physician stated that s/he had staff member #5 assist him/her with Resident #8's physical assessment on 10/25/23. Resident #8's attending physician stated orders were given to staff member #5 to obtain x-rays on 10/25/23 at approximately 1 PM. Further review on Resident #8's closed electronic medical record failed to reveal Resident #8 had any x-rays completed on 10/25/23. On 10/26/23, X-ray results indicated Resident #8 had an L1 compression fracture.
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2. Mechanical lift - also known as a patient lift is defined by the Food and Drug Administration (FDA) as being designed to lift and transfer patients from on place to another.
On 6/10/24 at 11:17 AM an observation of facility staff transferring Resident #66 from their bed to a wheelchair. Facility staff were in the Resident's room wheeling the resident out to the hallway where the wheelchair was located when the observation started. It was observed that as Certified Medicine Aide (CMA) #45 was wheeling the resident through the door the base of the mechanical lift was closed. The resident was suspended in the sling with his/her back towards CMA #45 and their head was touching the pole. Geriatric Nursing Assistant (GNA) #44 was holding the resident's feet as they came through the doorway. As they approached the wheelchair CMA #45 widened the base of the lift to fit around the wheelchair and GNA #43 tilted the wheelchair back on its back wheels with the front wheels off the ground as the resident was lowered into the chair. GNA #44 was guiding the resident into the chair. Licensed Practical Nurse (LPN) #46 was standing with the operator of the lift attempting to console the resident. Resident #66 was yelling out and said that staff had hit his/her head on the lift.
A medical record review for Resident #66 on 6/13/24 at 9:00 AM revealed a Minimum Data Set with the assessment reference date of 5/18/24 that documented in section GG the resident was dependent on staff to transfer him/her from the bed to the wheelchair.
A review of the instructions, provided by the Staff educator, titled, How to Use a Hoyer Lift was conducted on 6/10/24 at 12:00 PM. According to the manufacturer the base should be fully opened while the resident was
in the lift to maximize the stability of the lift. Further review revealed that once the resident was suspended in
the air and moved away from the surface, they should be turned to face the operator of the lift. Also, the resident should be lowered until they can rest their feet on the base of the lift.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0689 The operator of the lift, CMA #45 was interviewed on 6/10/24 at 11:44 AM. She reported that the base of the lift should be closed while the resident was in the lift. The base should be opened once the resident was at Level of Harm - Minimal harm or the wheelchair so the legs can straddle the wheelchair while the resident was lowered. potential for actual harm
An interview with GNA #43, who was the person holding the wheelchair, on 6/10/24 at 11:20 AM revealed Residents Affected - Few that she thought the base of the mechanical lift should be closed while the resident was being transported.
She stated the wheelchair should not have been tilted back but on the ground and the wheels locked.
During an interview with GNA #44, who was holding the resident's feet, on 6/10/24 at 11:23 AM she reported
it was not good to transfer the resident in the hallway but there was not enough room to transfer in the room.
She reported that the base of the mechanical lift should be closed while transferring the resident until the resident was being lowered then it should be opened.
An interview with LPN #46 on 6/10/24 at 11:31 AM revealed that she thought the base of the mechanical lift should be closed while moving the resident and then opened when placing them in the bed or chair. She stated the wheelchair should not have been tilted back but in an upright position with the wheels locked.
An interview with the Staff Educator on 6/10/24 at 11:53 AM revealed that they provide education regarding
the safe use of the mechanical lift upon hire and the periodically. Surveyor reviewed the observation of the mechanical lift transfer and the Staff Educator stated that the base of the lifts should have been opened while
the resident was in the lift. The resident should have been turned to face the operator while the GNA who was at the resident's feet should have been on their side guiding them. She stated that the wheelchair should not have been tilted back because it was not in a stable position and the resident could have fallen back.
The Director of Nursing (DON), who was the former staff educator was interviewed on 6/10/24 at 12:36 PM.
She stated that she educated staff to keep the base of the mechanical lift in a closed position while transporting them due to the limited space in a room. She confirmed that the resident should be facing the operator during transport and that would keep them from hitting their heads on the lift. She also confirmed that the staff person holding the resident's feet should have been standing to the side of the resident to guide and assist them if needed. She confirmed that the wheelchair should not have been tilted back while the resident was being lowered into the chair, but should have been fully on the floor with the wheels locked. She was asked to provide a copy of the education that she had provided to staff.
Review of the education revealed it was provided to staff on 8/24/23 and there was a checklist included which included that the resident should be facing the operator of the lift. However, it did instruct staff to close
the base of the lift while moving the resident between surfaces and to open the base at the chair or the bed while lowering the resident. This contradicts what the manufacturer's instructions to keep the base wide for stability of the lift. In addition, it had not included that the resident should be lowered to allow their feet to rest
on the base of the lift.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0689 A subsequent interview with the staff educator revealed that she was aware of the check list that were provided by the DON. She stated that the instructions she gave the surveyor was directly from the Level of Harm - Minimal harm or manufacturer and that was the safest way to use the lift. She was not aware that the resident should have potential for actual harm been lowered until their feet touched the base of the lift. She reported that she will review the manufacturer's instructions and add that to the training. Residents Affected - Few
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0692 Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm or 18819 potential for actual harm Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the Residents Affected - Few facility staff failed to 1. discharge a resident home with all of their belongings. This was evident for 1 (Residents #53) of 65 and 2. failed to accurately monitor and assess a resident's weights on admission. This was evident for 1 of 3 residents during a complaint survey (#60)
The findings include:
1. A review of Complaint MD00173266 on 06/10/24 revealed an allegation the facility lost Resident #53's dentures after admission. Resident #53 was discharged home on 09/27/21 and arrived without his/her upper dentures.
A review of Resident #53's closed medical record on 06/10/24 revealed a facility Speech Pathologist progress note, dated 09/13/21, that indicated Resident #53 was in possession of a set of upper dentures with sparse dentition on the bottom.
A review of Resident #53's nutrition/dietary progress note, dated 09/15/21 at 4:56 PM, the facility dietician documented that s/he spoke with Resident #53's family member who requested that the nursing staff place Resident #53's dentures in his/her mouth during meals. Further, the facility dietician documented that s/he asked the GNA staff member to help Resident #53 place his/her dentures in the Resident's mouth for improved oral intake and speech production.
Review of Resident #53's admission MDS, with an ARD date of 09/16/21, section L, revealed Resident #53 was admitted to the facility with no dental issues.
Review of Resident #53's nursing care plan, on 06/10/24, revealed Resident #53 was identified with a nutritional problem related to the need for a pureed diet, history of a stroke, dementia and hypertension. The facility dietician initiated a nutritional care plan on 09/13/21 with a goal to maintain an adequate nutritional status as evidenced by maintaining weight within +/- 5 % consistent body weight and consuming at least 50 - 75 % of at least 2 - 3 meals daily. Nursing interventions included: monitor/document/report PRN (as needed) any signs or symptoms of dysphagia, pocketing food, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, or appears concerned during meals, monitor/document/report to MD PRN signs and symptoms of malnutrition, emaciation, muscle wasting, significant weight loss: 3 pounds in one week, greater than 5 % in one month, greater than 7.5 % in 3 months, and greater than 10 %
in 6 months, and monitor intake and record every meal.
A review of Resident #53's GNA documentation records on 06/13/24 revealed that during Resident #53's 09/12/21 - 09/27/21 stay at the facility, the nursing staff documented that Resident #53 consumed 0-25 % for 17 of 46 meals and consumed 26-50 % for 14 of 46 meals. The nursing staff documented that Resident #53 consumed less than 50 % for 31 of 46 meals.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0692 Upon admission, Resident #53's physician instructed the nursing staff to monitor Resident #53's weight weekly x 4 weeks. On 09/12/21, the nursing staff documented that Resident #53 weighed 125 pounds. Level of Harm - Minimal harm or Review of Resident #53's closed record indicated that on 09/21/21, there was a problem obtaining a weight potential for actual harm for Resident #53 and instructed the reader to refer to the 09/21/21 nursing notes for additional information. Further review of Resident #53's closed record failed to reveal a reason why the nursing staff could not have Residents Affected - Few obtained a weight for Resident #53 on 09/21/21 - 09/27/21 while Resident #53 continued to reside in the facility.
In an interview with the facility director of nurses (DON) on 06/13/24 at 12:48 PM, the DON stated the speech pathologist (SLP) that reviewed Resident #53 during the 09/12/21 admission no longer works at the facility.
In an interview with the facility director of nurses (DON) on 06/13/24 at 1:30 PM, the DON stated the dietician that reviewed Resident #53 during the 09/12/21 admission no longer works at the facility.
30428
2. Medical record reviews on 6/14/24 at 9:39 AM for Resident #60 while investigating complaint #MD00165852 revealed on 3/16/2021 the facility staff documented his/her weight as 290 pounds (lbs.). This was documented again on 3/26/21. However, on 4/6/21 staff documented residents' weight as 181.
Resident #60 was admitted to the facility post left leg amputation above the knee.
An admission nutrition assessment was completed by the previous dietitian (RD) on 3/18/21 and noted that
the resident is unable to communicate and newly admitted with a left AKA (above knee amputation), however, still documented the resident as weighing 290lbs.
On 4/7/21, the RD saw Resident #60 again.
The RD struck out the weights in the computer from 3/16/21 and 3/26/21 documenting that those weights are not the residents actual body weights. The progress note, dated 4/7/21, continued to state that the resident was weighed and noted to be 180 lbs., which is 100lbs less than what was previously documented. The resident, who can verbally communicate and noted to have capacity, stated during the 4/7/21 meeting with
the RD, that his/her normal weight was between 220-230 lbs. prior to the AKA. The previous RD also stated
in the same progress note that visual observation confirms this weight as well, which disputes the admission assessment where he documented the weight of 290 lbs. just 3 weeks prior.
The current facility dietitian, staff #29 was interviewed on 6/17/24 at 9:35 AM regarding the facility policy/process on meeting with residents on admission. She stated that for her it is within 72 hours. The RD progress notes were reviewed for Resident #60 with staff #29. Although there was an initial assessment on 3/18/21 it was not reflective of the actual resident including the documented weights. Additionally, according to the 4/7/21 progress note, it revealed that the previous RD had not actually visited or seen and confirmed
the weights of the resident until 4/7/21 when he stated that the residents documented weight of 180 was confirmed by visual observation 3 weeks after the resident was admitted . The concern that the initial assessment had based the diet on a weight that was 100lbs. different than the resident's actual weight was also reviewed.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0692 This concern was reviewed with the current facility RD on 6/17/24 at 9:38 AM as well as the DON on 6/17/24 and again at exit on 6/18/24. Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0711 Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. Level of Harm - Minimal harm or potential for actual harm 30428
Residents Affected - Few Based on medical record review and interview with facility staff, it was determined that the physicians failed to have their notes in the medical record timely after seeing the resident. This was evident for 1 of 65 (#4) Residents reviewed during a complaint survey.
The findings include:
When the medical record of Resident #4 was reviewed on 6/12/24 at 1:11 PM a physician discharge note with an effective date of 5/19/24 was the first note to appear. However, Resident #4 was discharged from the facility on 3/22/24 to the emergency room and had not returned. This physician discharge note said that it was completed on 3/14/24. However, according to the resident's census report, s/he had been in and out of
the facility twice since the note was written.
This identified concern of the delay to have the physician note in the chart timely was reviewed with the DON
on 6/12/24. At approximately 1:30 PM on 6/12/24 the DON was asked what the expectation and process was to have physician notes in the resident medical records. She stated that the notes are to be completed and in
the charts within 30 days.
The delay of an additional 30 days to have a discharge summary in the medical record was reviewed with
the DON on 6/12/24 and during exit on 6/18/24.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Level of Harm - Minimal harm or potential for actual harm 30428
Residents Affected - Few Based on the review of a facility reported incident (FRI) #MD00204392 related to an allegation of abuse, a
review of employee files and interviews, it was determined that the facility failed to ensure Geriatric Nursing Assistants (GNAs) were competent with their skill sets. This was found to be evident for 1 out of 5 employee files reviewed for competencies and skill sets.
The findings include:
Review of the FRI #MD00204392 on 6/11/24 at 9:07 AM revealed an allegation of abuse occurring with Resident #3 at the hands of GNA #7.
A review of the facility investigation and concurrent review of the employee file for GNA #7 revealed that upon hire on 8/6/19 the Certified Nursing Assistant competency check off sheet was never completed.
The DON was interviewed on 6/11/24 at 10:10AM. This concern was brought to her attention as she was present and had completed this investigation and investigation packet. She was not aware of the blank competency check list. She was asked at this time for anything further or any education or training that was completed with staff GNA #7 since her hire. This request was followed up on every day of the survey.
As of exit on 6/18/24, no further documentation or training was provided to the survey team.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 30428
Residents Affected - Few Based on the review of a complaint, resident interview and interview with the facility staff, it was determined that the facility failed to timely provide a resident with an established psychiatric diagnosis with therapeutic treatment to maintain his/her highest practicable well-being. This was evident during the review of 1 of 65 residents (#33) reviewed during a complaint.
The findings include:
Review of the complaints for Resident #33 on 6/17/24 at 10:17 AM, #MD00174214 and #MD00180447 revealed concerns related to general care in the facility and the fact that s/he battles with severe depression and anxiety and with the lack of care and neglect that [s/he] is not receiving, the depressive and anxiety episodes are increasing. The complaints also noted that the individual was under [AGE] years old.
Continued record review revealed that Resident #33 has been a resident of the facility since February 2020. Admitting diagnosis' included acute transvers myelitis (a rare neurological condition that causes inflammation of the spinal cord) which has caused paraplegia, additionally admission diagnosis included major depressive disorder and unspecified psychosis not due to substance or known psychological condition.
On admission in 2020, the attending physician ordered for a psychiatric consult. This order was in place from 2/26/2020 through 6/5/2020. At no time between those dates was a psychiatric consult completed.
Review of Resident #33's care plans on 6/17/24 at 12:37 PM revealed that a behavior care plan was initiated for refusal to allow skin assessments on 8/22, lab refusals, yelling and throwing items at staff occurred in the month of 9/22, and further yelling at staff and medication refusals was updated in the care plan between January and February of 2023. However, even with these changes in behaviors at no time was there an updated order or a referral for the facility psychiatrist to see the resident.
On 3/1/23 Resident #33 was seen by the facility psychiatrist for the first time to evaluate mental status and adjust medications for behavioral disturbances. Patient seen to evaluate for depression, Patient seen to evaluate for agitation, Patient seen to evaluate for anxiety.
At the time of the evaluation, Resident #33 was not on any medication and further was not prescribed any psychiatric medication, only 1:1 supportive therapy was recommended.
Surveyor met with Resident #33 on 6/18/24 at 7:45 AM. Resident #33 was verbally frustrated at the lack of attention and care that s/he receives from the staff for regular activities of daily living as s/he is dependent for care. S/he stated that the staff will argue with each other about helping with care and that there are long waits up to 45 minutes for someone to answer the call bells.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0740 This surveyor reviewed the concerns in his/her complaint. S/he stated that until s/he came to this facility 4 years ago, his/her psychiatric well-being was ok. It wasn't until they were admitted here and had to just sit in Level of Harm - Minimal harm or bed because of their diagnosis (paraplegia) and have become dependent on staff that their mental health potential for actual harm diminished.
Residents Affected - Few This surveyor asked about the facility providing any mental health services. Resident #33 stated that it was limited, and nothing provided to him/her when they were first admitted to the facility when they were trying to adjust.
The facility social worker, staff #30 was interviewed on 6/18/24 at 8:40 AM. She reviewed the process of completing trauma screens on residents and stated that if nothing triggers, no care plan is completed, and
they are only completed on the initial admission or if there is a significant change and even then, it may or may not trigger the facility to complete a new screen. The incidents and history of Resident #33 was reviewed including his/her multiple re-hospitalization s that had lasted for weeks. She stated that none of those incidents had triggered for a new trauma screen to be completed or for him/her to be reassessed for any behavior screening or monitoring, even the occurrences in 2022 and 2023 with the care refusals.
The DON was interviewed on 6/18/24 at 8:47 AM. The concern that there were no documented psychiatric services provided or offered to an atypical nursing home resident newly diagnosed with paraplegia related to
the transverse myelitis admitted to the facility in 2020 with identified behaviors in 2022 and 2023 was reviewed at this time.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0760 Ensure that residents are free from significant medication errors.
Level of Harm - Minimal harm or 37296 potential for actual harm Based on clinical record review and staff interview it was determined that the facility staff failed to administer Residents Affected - Few medications according to the physician orders. This was evident for 1 out 1 resident (#51) in the complaint sample.
Documentation is an integral part of medication administration. Documentation communicates the timing, dosing, and effect of any medications received by a patient. In the setting of skilled nursing care, residents are often prescribed multiple medications for significant medical conditions. They are also often more vulnerable to medication error and more prone to changes in condition that require review and adjustment of their medication regimen. Inaccurate medication documentation has the potential to place residents at significant risk of medication error, provide incomplete or inaccurate information for providers and care givers to evaluate, and represents a failure of basic medication administration principles.
Late documentation is a form of inaccurate documentation and is worsened if the documentation does not document when medications were actually given. 'Late administration' is defined as giving medication greater than 1 hour after a medication is due. 'Late documentation' is defined as not documenting immediately after administration.
The findings include:
On 6/13/24 at 11 Am, an investigation of complaint MD174252 alleges that Resident #51 was not getting his/her pain medication on time,
A review of Resident #51's medication administration record (MAR) for a period covering November 10, 2021, thru November 18, 2021, revealed a significant pattern of late documentation for the pain medication that the resident was prescribed.
The resident was prescribed:
1. Morphine Sulfate ER tablets 15mg every 12 hours for pain. (supplement). The medication was administered late for 7 out of 16 opportunities.
2. Lantus Solostar pen injector 100 units/ml inject 75 units (treats diabetes). The medication was administered late for 5 out of 15 opportunities.
3. Humalog 100 unit/ml to be dosed on a sliding scale (treats diabetes). The medication was administered late for 6 out of 16 opportunities.
Interview with the Director of Nursing on 6/14/24 at 10:15 AM confirmed the facility staff failed to ensure Resident #51's medications were given as prescribe.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0790 Provide routine and 24-hour emergency dental care for each resident.
Level of Harm - Minimal harm or 18819 potential for actual harm Based on complaint, reviews of a closed medical record, and staff interview, it was determined that the Residents Affected - Few facility staff failed to discharge a resident home with all of their belongings. This was evident for 1 (Residents #53) of 65 residents reviewed during a complaint survey.
The findings include:
A review of Complaint MD00173266 on 06/10/24 revealed an allegation the facility lost Resident #53's dentures after admission. Resident #53 was discharged home on 09/27/21 and arrived without his/her upper dentures.
A review of Resident #53's closed medical record on 06/10/24 revealed a facility Speech Pathologist progress note, dated 09/13/21, that indicated Resident #53 was in possession of a set of upper dentures with sparse dentition on the bottom.
A review of Resident #53's nutrition/dietary progress note, dated 09/15/21 at 4:56 PM, the facility dietician documented that s/he spoke with Resident #53's family member who requested that the nursing staff place Resident #53's dentures in his/her mouth during meals. Further, the facility dietician documented that s/he asked the GNA staff member to help Resident #53 place his/her dentures in the Resident's mouth for improved oral intake and speech production.
Review of Resident #53's admission MDS, with an ARD date of 09/16/21, section L, revealed Resident #53 was admitted to the facility with no dental issues.
In an interview with the facility director of nurses (DON) on 06/13/24 at 12:48 PM, the DON stated the speech pathologist (SLP) that reviewed Resident #53 during the 09/12/21 admission no longer works at the facility.
In an interview with the facility director of nurses (DON) on 06/13/24 at 1:30 PM, the DON stated the dietician that reviewed Resident #53 during the 09/12/21 admission no longer works at the facility.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 34484
Residents Affected - Few Based on medical record review and staff interview, it was determined the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards (Resident #25 and #51).
This was evident for 2 of 65 residents reviewed during a complaint survey.
The findings include:
A medical record is the official documentation for a healthcare organization. As such, it must be maintained
in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate.
1. Review of Resident #25's medical record on 6/17/24 revealed the Resident was admitted to the facility to 2/28/23 following crainiectomy surgery. A craniectomy is a major brain surgery that involves removing part of
the skull to relieve pressure on the brain.
Further review of the medical record revealed a physician note on 4/4/23 that stated: Patient getting ready for his/her neurologist appt today, states doing well. Further review of the medical record revealed no documentation from the neurologist appointment.
On 6/17/24 at 1:06 PM the Surveyor asked the Director of Nursing (DON) for the documentation from the neurologist appointment on 4/4/23. The DON was unable to provide the neurologist appointment progress notes until 6/18/24.
Interview with the Director of Nursing on 6/18/24 at 11:15 AM confirmed the facility staff failed to have the 4/4/23 neurologist appointment notes in Resident #25's medical record and had to call to have them sent to
the facility on [DATE REDACTED].
37296
2. On 6/14/24 at 11:30AM, a medical record review determined the facility staff failed to maintain complete and accurate medical records. A request was made to the Director of Nursing for the Controlled Medication Utilization Record sheets for Resident #51 prn pain medications.
On 6/17/24 at 12 PM, the Director of Nursing confirmed that the Controlled Medication Utilization Record sheets was not included in Resident's #51 medical record and is unable to locate.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.
Level of Harm - Minimal harm or 42886 potential for actual harm Based on a facility's Quality Assurance and Performance Improvement (QAPI) record review and interview, Residents Affected - Few the facility failed to adequately monitor malfunctions in the facility's hot water heating system.
QAPI Plan
A written plan that contains the process that will guide a facility in their efforts to assure care and services are maintained at acceptable levels.
QAPI Committee
A group consisting of a facility's administration department and selected other facility staff that review the facility's process to ensure care and services are maintained at acceptable levels.
Findings include:
The State of Maryland's Department of Health Office of Health Care Quality received a complaint (MD00193286) from resident #17 which alleged that facility was having issues with providing hot water to resident's rooms.
On 6/10/24 at 11:42am, the surveyor interviewed maintenance director #2 regarding resident #17's allegations of the facility failing to maintain hot water in resident's rooms in the month of 6/2023. Maintenance Director #2 stated that he/she was unaware of hot water issues in the summer of 2023 because he/she was not employed with the facility at the time. Maintenance Director #2 stated that he/she started working for the facility in August 2023. Maintenance Director #2 provided the surveyor with a QAPI plan describing the facility's actions to repair the hot water heating system. The QAPI plan started on 11/27/23 and ended 1/3/24. Maintenance Director #2 stated that the facility's dysfunctional hot water heating system affected only resident rooms on one side of the facility. The facility contacted a repair company immediately and provided hot water from the kitchen in portable vessels for bathing.
Surveyor review of the QAPI plan and accompanied invoices for repair of the malfunctioning hot water heater system on 6/11/24 at 8:30am revealed the facility's hot water heating system was malfunctioning due to a broken circulation pump. The accompanied temperature readings revealed the 1st floor shower room recorded temperatures of 140 F from 1/3/24 - 1/5/24 and 1/9/24. Review of the QAPI plan stated that Maintenance Director #2 would take hot water temperature daily throughout the facility for 90 days. The QAPI plan also stated that the QAPI committee would review the temperatures.
During a surveyor interview with Maintenance Director #2 on 6/11/24 at 11:37am, the surveyor pointed out
the 1st floor shower room temperatures from 1/3/24 -1/5/24 and 1/9/24 were 140 F. Maintenance Director #2 stated that those temperatures recorded in error. The surveyor asked Maintenance Director #2 the hot water temperature range is acceptable based on facility policy. The hot water temperature range was stated as 100 F to 120F.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 46 215168 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 215168 B. Wing 06/18/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Layhill Nursing and Rehabilitation Center 3227 Bel Pre Road Silver Spring, MD 20906
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 0865 During a surveyor Interview of the Administrator on 6/11/24 at 11:54am, the surveyor informed the Administrator of the 140 F hot water temperatures recorded for 1/3/24 - 1/5/24 and 1/9/24. The Administrator Level of Harm - Minimal harm or stated that he/she was not employed with the facility at the time of the hot water system malfunction. The potential for actual harm Administrator also stated that he/she would expect Maintenance Director #2 to inform him/her of the temperature anomaly. The surveyor also pointed out that the QAPI plan stated that the hot water Residents Affected - Few temperatures would be taken daily for 90 days. The surveyor asked the Administrator if the QAPI committee is expected to review the hot water temperatures after Maintenance Director #2 takes them. The Administrator stated that he/she would expect the QAPI committee to review the temperatures to make sure
the hot water system is functioning properly. Also, the surveyor also asked if the facility informed the OHCQ of the malfunctioning hot water heating system from 11/23 to 1/24. The Administrator stated that he/she was unable to find proof that OHCQ was informed of the malfunctioning hot water heating system. The surveyor expressed concerns that the QAPI committee failed to show good faith when they failed to review the hot water temperatures as listed on the QAPI plan and the facility failed to inform OHCQ of their malfunctioning hot water heating system from 11/23/24 - 1/24/24.
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 46 215168