Montcare at Potomac

In the surveyor’s words

From the most serious findings on record at Montcare at Potomac, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF885Jan 20, 2022

  Based on the review of the facility administrative records and interview it was determined the facility failed to have a mechanism in place that provided notification to residents of the facility ' s Covid-19 status. This was found to be evident for all residents. Findings include: A review of the facility administrative records on 01/19/2022 at 11:07 am, the Surveyor was unable to identify a record of notification to all residents for the facility ' s Covid-19 status. During an interview conducted on 01/19/2022 at 11:25 am the Administrator confirmed the facility did not have a mechanism in place to notify all residents of the facility ' s Covid-19 Status. […]

• No harm, potential for more than minimal, isolatedF641Feb 18, 2026

  Based on record reviews and interviews, it was determined that the facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded, including coding related to wander/elopement risk status. This was evident for 2 (Residents #108 and #154) out of 5 residents reviewed for accidents during the recertification survey.The findings include: 1.Resident #108 diagnoses included Vascular Dementia and Depression. A review of Resident #108's clinical record on 2/13/26 at 8:00 AM revealed the quarterly Minimum Data Set (MDS) assessments with Assessment Reference Data (ARD) of 09/30/25 and 12/30/25 were inaccurately coded. […]

• No harm, potential for more than minimal, isolatedF656Feb 18, 2026

  Based on observation, record review, and interview, it was determined that the facility failed to develop and implement comprehensive care plan regarding the use of a nebulizer. This was evident for 1 (Residents #1) of 41 residents reviewed for care planning during the recertification survey.The findings include: 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 care plan consists of focus, goal and interventions. […]

• No harm, potential for more than minimal, isolatedF657Feb 18, 2026

  Based on observation, clinical record reviews and interviews, it was determined that the facility failed to review and revise care plans to meet the specific needs of the residents. This was evident of 3 (Residents #4, #111 and #91) out of 41 residents reviewed for care plan timing and revision during the recertification survey. The findings include: 1. On 02/11/26 at 11:32 AM, a review of Resident #4's clinical record revealed that the resident was prescribed Triamterene-HCTZ 37.5-25 mg 1capsule by mouth once a day for Hypertension on 10/17/24. The resident was administered the medication from 10/17/24 until 12/24/24 when it was discontinued. Further review revealed an active Care Plan for Resident #4 with focus Resident is on diuretic therapy (HCTZ) r/t hypertension. […]

• No harm, potential for more than minimal, isolatedF677Feb 18, 2026

  Based on observation, interview and record review, it was determined that the facility failed to provide necessary personal hygiene to dependent residents. This was evident for 2 (Residents #111 and #91) of 5 residents reviewed for Activities of Daily Living (ADLs) during the recertification survey.The findings include: ADL is a term used collectively to describe fundamental skills required to independently care for oneself, such as eating, bathing, and mobility. Minimum Data Set (MDS) is a core set of screening, clinical, and functional status data elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. […]