Layhill Nursing And Rehabilitation Center

Based on record review and interviews it was determined that the facility failed to ensure a Resident Fund Account was accurately managed.

This was found to be evident for 1 (Resident #14) out of 1 Resident reviewed for resident funds during the complaint survey.

The findings include: During a review of complaint #365431 conducted on 10/08/25 at 10:00 AM it was reported that the facility had not managed Resident #14's fund account accurately.

During a review of Resident #14's billing record conducted on 10/08/25 at 10:07 AM, it was revealed that the Resident was charged $571 for Beauty Shop/Barber services.

During an interview conducted on 10/08/25 at 10:11 AM, the Business Office Management (BOM) explained that the previous BOM failed to pay for Beauty Shop /Barber service charges that the Resident had incurred for 1 year.

The BOM stated that she would provide the accounting of the barber services.

During a review of the Senior Salon log sheets conducted on 10/08/25 at 10:32 AM, it was revealed that Resident#14's barber chargers totaled $515 and not $571 that was charged to the Resident.

During an interview of the BOM conducted on 10/08/25 at 10:49 AM.

The BOM confirmed that there were accounting errors and Resident #14 was overcharged.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

Based on review of the facility's investigative report and staff interview, it was determined the facility failed to report an allegation of abuse to the State Survey Agency, which was the Office of Health Care Quality (OHCQ) within 24 hours of the alleged incident.

This was found to be evident for 2 (Resident #19 and #7) out of 7 Residents reviewed for abuse during the complaint survey.

The findings include: 1) On 10/6/25 at 9:00AM a review of Resident # 19's clinical record revealed that the resident was admitted to the facility with diagnoses which included Shortness of Breath, Dementia and Osteoarthritis of the Right Shoulder.

Further review of Resident #19 clinical record revealed the resident sustained 2 large skin tears on both forearms while being assisted out of his/her chair by Hospitality Aide #12 who was not qualified to provide care to the resident.

The sizes of the skin tears were not documented in the clinical record.

However, in Complaint #365421 the resident's representative stated that the skin tears measured 2.5 inches by 1.65 inches.

Hospitality Aide #12 confirmed in a written statement that the resident sustained skin tears on the forearms when he tried to assist him/her out of the chair.

On 10/06/25 at 12:19 PM in an interview the Director of Nursing (DON) stated that the facility employed Hospitality Aides and their duties include greeting residents and filling water pitchers.

They could answer call lights, but they are not allowed to touch the residents or provide care.

The DON stated that she was unfamiliar with the incident but would review the facility's documentation.

Later at 2:00PM PM on 10/6/25 the DON stated that she located a soft file with investigative notes which she provided to the surveyor. A review of the soft file and of Resident #19's clinical record failed to reveal the incident was reported to the Office of Health Care Quality.

The DON confirmed the surveyor's findings. 2) During a review of Facility Reported Incident (FRI) #365432 investigation conducted on 10/09/25 at 8:45AM, it was discovered that Resident #7 reported an allegation of abuse to Unit Manager #15 on 05/18/25.

However, the facility did not report the allegation of abuse until 05/21/25.

During an interview conducted on 10/09/25 at 9:17 AM, the Director of Nursing (DON) explained that Unit Manager #15 failed to report the allegation of abuse to the Administration.

The DON reported that on 05/21/25 Resident #7 reported the allegation of abuse to the DON and Administrator, at which time she immediately reported the allegation of abuse to the State Agency OHCQ.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a complaint investigation, record reviews, and staff interviews, it was determined that the facility failed to ensure a complete and accurate written discharge summary was provided to a resident at the time of discharge.

This was evident for 1 (Resident #2) of 1 resident reviewed for transfer and discharge process during the complaint survey.The findings include:Total Parenteral Nutrition (TPN) is nutrition provided through an intravenous (IV) line when a resident is unable to eat or absorb nutrients by mouth.Intravenous (IV) means within a vein.

This allows the medicine or fluid to enter the bloodstream right away.On 10/08/25 at 10:17 AM, Resident #2's closed medical record was reviewed in relation to complaint #2563521.

Resident # 2 was discharged to a group home on [DATE] with an abdominal drain and total parenteral nutrition (TPN). On 10/08/25 at 11:57 AM, a review of Resident #2's Discharge summary, dated [DATE], revealed that the nursing instructions section was incomplete.

Information regarding Resident #2's TPN management, abdominal drain care, patient education provided, and a complete list of medications was not documented on the discharge instructions. On 10/08/2025 at 1:27 PM, review of the facility's policy titled Discharge Instructions, effective 01/29/2024, revealed that a licensed nurse will complete all applicable nursing sections of the discharge instructions prior to discharge.In an interview on 10/08/2025 at 1:45 PM, Social Worker #8 stated that each discipline is responsible for completing their assigned sections of the discharge summary and that nursing staff complete the medication and treatment areas.On 10/08/2025 at 2:33 PM, review of Resident #2's physician orders revealed that he/she was receiving TPN and had an abdominal drain in place at the time of discharge.On 10/09/2025 at 9:31 AM, an interview with the Director of Nursing (DON) confirmed that the nursing sections of Resident #2's discharge summary were incomplete and did not reflect the resident's current status at the time of discharge.

The DON stated that Resident #2 was discharged to a group home with TPN supplies, an abdominal drain, and actual prescribed medications in hand.

The DON further stated that it is the expectation that all disciplines, including nursing, complete appliable areas on the discharge summary form prior to the resident's discharge from the facility.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

The surveyor reviewed Complaint #2624448 which was submitted anonymously and stated that the facility failed to provide appropriate care to the resident after a fall.On 10/08/25 at 10:21 AM a review of Resident #8's clinical record revealed that the resident fell on [DATE] at 8:00 PM in his/her room while trying to get something from his/her drawer. A Licensed Nurse completed an assessment which included neuro checks and documented that there were no injuries.A further review revealed a Nurse's Note Post Fall Documentation dated 9/12/2025 at 20:32 labeled Late Entry stated Recommendation: Interventions currently in place to prevent additional falls: bed in low.

Upon review of the resident Care Plans, the surveyor observed that Resident #8's Care Plan for falls was initiated on 8/20/25 and revised on 09/12/25.

The Care Plan failed to reveal an intervention for a low bed to prevent falls as stated in the nurse's note.

During an interview on 10/08/25 at 11:24 AM Unit Manager Staff #3 reviewed the clinical record and confirmed the surveyor's findings.

Unit Manager Staff #3 stated that ensuring a resident's bed is in a low position is a standard intervention to prevent falls and the intervention should have been included in Resident #8's plan of care.On 10/08/25 at 12:32 PM during an interview the Director of Nursing also reviewed the clinical record and confirmed the findings.

The DON stated that staff is expected to review and update Care plans in a timely manner when new interventions are put in place.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

Based on this review it was determined that the facility's past non-compliance period was from 03/11/25 through 05/05/25.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

The surveyor observed that Resident #21's dressing to the Left Elbow was not initialed and not labeled as to when it was last changed and on what shift. 2) Resident #22's clinical record revealed a physician order dated 08/01/25 which stated Right Lateral Knee: 1.

Cleanse with wound cleanser, pat dry. 2.

Cut Gentell Blue to the size of the wound. 3.

Apply Gentel Blue directly [NAME] the wound bed and fill cavity- **It can be rolled or layered and packed into the wound. 4.Cover with silicone bordered super absorbent dressing. 5.

Change Monday, Wednesday, Friday and PRN every day shift every Mon, Wed, Fri.

Start Date: 08/04/25The surveyor observed that Resident #22's dressing to the Right Knee was not initialed and not labeled as to when it was last changed and on what shift.

During the observation, in an interview, Wound Nurse RN #2 who accompanied the surveyor confirmed the findings.

Wound Nurse #2 stated that the standard practice for dressing changes was for the Licensed Nurses to initial, date and label the dressings to indicate when the dressing change occurred.

Wound Nurse RN #2 was unable to tell the surveyor who changed the dressings and on what shift. On 10/07/25 at 8:18 AM the Nurse Educator in an interview was informed of the surveyor's concerns, and she indicated that she would educate the nurses.On 10/7/25 at 8:42 AM in an interview, the Director of Nursing (DON) was notified of the surveyor's concerns.

The DON stated that she was aware of the findings and that Inservice training on dressing changes had already started on 10/6/25.

She gave the surveyor a copy of the Inservice document.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

Based on medical record reviews and staff interviews, it was determined that the facility failed to provide treatment and services necessary to prevent pressure ulcer.

This was evident for 1 (Resident #16) out of 1 resident reviewed for facility acquired pressure ulcer during the complaint survey process.

The findings include:An in-house acquired pressure ulcer is a skin or tissue injury that develops while a resident is in the nursing facility, which was not present at the time of admission.

These pressure ulcers occur due to prolonged pressure, friction, shear, or other risk factors and indicate a failure to implement preventive measures or provide timely interventionsDuring record review on 10/08/25 at 7:30 AM, it was revealed that Resident #16 was admitted from the hospital to the facility on 2/27/2025 with medical diagnoses of morbid (severe) obesity due to excess calories and type 2 diabetes mellitus without complications and had no pressure ulcers at the time of admission.On 10/08/25 at 8:00AM review of Resident #16's admission assessment record revealed a Braden Scale assessment for predicting pressure sore risk.

The Braden Scale is an evidence-based tool that predicts the risk of developing a hospital or facility-acquired pressure ulcer/injury.

The scale uses scores ranging from 6 to 23, with lower scores indicating higher risk for developing an acquired ulcer/injury. Resident #16 scored 15 on the Braden Scale, indicating mild risk, while a score of 19-23 is considered no risk for developing a pressure sore.On 10/08/25 at 8:20 AM, review of the medical record revealed that on 3/10/2025, Resident #16 developed an unstageable pressure ulcer to the sacral area while in the facility, measuring 2.40 cm in length x 0.80 cm in width x 0.20 cm in depth, with a calculated area of 1.92 cm^2 and 100% slough, according to the wound physician's notes.

Further review revealed that no change in condition assessment was completed, and the resident's family representative was notified of the change. On 10/08/25 at 10:30 AM, medical record review revealed that the wound assessment report dated 3/24/25 indicated the Resident #16's wound remains unstageable, measured 2.60 cm in length x 1.90 cm in width x 0.20 cm in depth, with a calculated wound area of 4.94 cm^2.During interview with the Director of Nursing (DON) on 10/08/25 at 11:20AM, she stated Resident #16 was admitted with left buttock incontinent associated dermatitis, right abdominal fold and a blister on the right tight.

She confirmed that the resident acquired in-house unstageable pressure ulcer at the sacrum on 3/10/25. On 10/08/25 at 11:25 AM, the Director of Nursing (DON) confirmed that no change in condition assessment was completed for the in-house acquired pressure ulcer.

When asked if the family was notified of the change, she stated, 'I do not see family or resident notification.' The DON further stated that the facility's expectation is for nurses to complete a change in condition assessment and to notify residents or their representatives of any change in condition. On 10/08/25 at 11:35 AM, the surveyor made the DON aware of the above concerns, and she acknowledged receipt.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

Based on record review, interviews and review of facility investigation documents, it was determined that the facility failed to keep a resident free from accidents and hazards by failing to provide a qualified caregiver to assist the resident.

This was evident in 1 (Resident #19) of 1 resident reviewed for accidents and hazards during the complaint survey.The findings include:A review of Complaint #365421 made by Resident #19's Representative stated that the resident was observed on 10/21/24 with 2 lacerations on both arms, both measured 2.5 inches by 1.65 inches.

Further, they were not notified of the injuries and when asked, the facility gave four different versions of the incident.On 10/6/25 at 9:00AM a review of Resident # 19's clinical record revealed that the resident was admitted to the facility with diagnoses which included Shortness of Breath, Dementia and Osteoarthritis of the Right Shoulder.Further review of the clinical record revealed a note dated 10/20/24 at 16:30 by LPN Staff #9 which stated that she was called to the resident's room and observed two large skin tears on both forearms of the resident.

The resident was non-English speaking, so the LPN Staff #9 got an interpreter.

Through the interpreter, the resident stated that he/she was being assisted by a staff member to get out of the chair to go to the bathroom when the incident occurred.

The physician was notified, and the skin tears were treated in keeping with the physician orders.

The note continued RP (resident representative) not reachable, message left to call back the facility.

The surveyor noted that the documentation failed to reveal the size of the skin tears. On 10/06/25 at 11:22 AM the surveyor interviewed LPN Staff #9 who repeated what was written in her note dated 10/20/24. LPN Staff #9 stated that the staff member who assisted the resident was a Hospitality Aide #12 who was not supposed to provide care or get the resident out of the chair.

She informed Hospitality Aide #12 that he should not have touched the resident, obtained a statement from him then reported the incident her supervisor. LPN Staff #9 confirmed that she did not measure the Skin Tears. On 10/06/25 at 12:19 PM in an interview the Director of Nursing (DON) stated that the facility employed Hospitality Aides, and their duties include greeting residents and filling water pitchers.

They could answer call lights, but they are not allowed to touch the residents or provide care.

The DON stated that she was unfamiliar with the incident but would review the facility's documentation.

Later at 2:00 PM on 10/6/25 the DON stated that she located a soft file with investigative notes which she provided to the surveyor.

The DON also provided the surveyor with a copy of a job description for Hospitality Aides.

The document was entitled Job Description - Personal Care Aide (PCA) revised in December 2022. In the document under Heading - Supportive Tasks the document stated PCAs are not permitted to perform direct patient care, even if supervised A review of the soft file revealed a statement dated 10/20/24 from Hospitality Aide #12 confirming that the resident sustained skin tears when he assisted them to get up from the chair.

The file also contained documentation that an Inservice was provided to Hospitality Aides emphasizing boundaries of their responsibilities to ensure patient safety and proper care.

The concern that a resident was injured by a staff member who was not qualified to provide care was brought to the attention of the DON.

The DON stated that she reviewed the documents and confirmed the surveyor's findings.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

During a review of the Resident #5's medical records conducted on 10/06/25 at 10:07 AM, it was discovered that the Resident was transferred and admitted to a local hospital on [DATE]. A review of Resident #5's hospital discharge summary conducted on 10/06/25 at 10:19 AM revealed a discharge medication list.

The discharge medication list dated 03/11/25 showed 2 anti-rejection medications: Sirolimus 0.5 mg (milligram) tablet every 24 hours, and Tacrolimus 2 (1) mg capsules every 24 hours. A review of Resident 5's Physician orders and Medication Administration Record (MAR) conducted on 10/06/25 at 10:33 AM for March and April 2025 did not show an order for Sirolimus 0.5 mg tablet every 24 hours and Tacrolimus 2 (1) mg capsules every 24 hours.

The review confirmed that the Resident had not received the anti-rejection medications as listed on the discharge medication list on 03/11/25.During a telephone interview conducted on 10/07/25 at approximately 1:00 PM, Certified Registered Nurse Practitioner (CRNP) #16 explained that when a Resident was to be admitted to the facility she would review the hospital discharge summary to determine the resident's level of care which included reviewing the medication list.

The CRNP #16 further explained that she does not change or stop any of the medications listed on the discharge medication list.

When asked does she reconcile the Resident's admitting medications, the CRNP #16 responded yes.

When asked how the medications were reconciled she stated she used the hospital discharge summary medication list.

When asked did she reconcile the medications for Resident #5 the CRNP #16 stated she does not have access to the Medications Administration Record (MAR) only to the Electronic Health Record (EHR), but that she could review the medications listed in the EHR.

When asked did she reconcile the medications for Resident #5, the CRNP replied no because the admitting nurse completes that task.

This Surveyor reminded the CRNP that she earlier stated that she reconciles the medications, the CRNP replied it is the admitting nurse responsibility.

When asked if the CRNP #16 notice that the heart transplant Resident was not on any anti-rejection medication she stated no I was focused on the Resident's heart failure medications.

During an interview conducted on 10/07/25 at 1:47 PM, the Director of Nursing (DON) confirmed that the admitting nurse will place the order for each admitting medication however the provider is expected to reconcile the medication list.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Layhill Nursing and Rehabilitation Center

3227 Bel Pre Road Silver Spring, MD 20906

SUMMARY STATEMENT OF DEFICIENCIES

During an interview conducted on 10/06/25 at 10:49 AM, the Director of Nursing (DON) explained that when a Resident is admitted , the pharmacy has a responsibility to review the hospital discharge medication list and reconcile the medications.

The DON confirmed that the pharmacy completed Resident #5's admission medication review however they overlooked the 2 anti-rejection medications.

Facility ID: