Potomac Falls Health & Rehab Center

In the surveyor’s words

From the most serious findings on record at Potomac Falls Health & Rehab Center, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF645Sep 17, 2025

  Based on interview and record review, the facility failed to ensure the accuracy of a preadmission screening and resident review (PASARR) for 4 (Residents #5, #11, #16, and #140) of 5 sampled residents reviewed for PASARR.Findings included: During an interview on 09/15/2025 at 10:26 AM, the Administrator stated the facility did not have a PASARR policy and followed the guidance in the regulation. 1. An admission Record indicated the facility admitted Resident #11 on 01/18/2023. According to the admission Record, the resident had a medical history that included diagnoses of anxiety disorder and adjustment disorder with anxiety. […]

• No harm, potential for more than minimal, patternF656Dec 2, 2021

  Based on resident interview, staff interviews, and clinical record review, the facility staff failed to develop and implement a comprehensive person-centered care plan to address the preference of the resident for staff not to pull on her arms/shoulders which introduced pain during bed mobility and transfers for 1 of 45 residents (Resident #39), in the survey sample. The findings included: Resident #39 was originally admitted to the facility 4/30/21 and has not been discharged from the facility. The current diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 9/26/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 14 out of a possible 15. […]

• No harm, potential for more than minimal, patternF760Dec 2, 2021

  Based on staff interviews, clinical record review and facility document review, the facility staff failed to ensure 1 of 45 residents (Resident #74) in the survey sample were free of significant medication error. The findings included: The facility staff failed to ensure the following significant medication ([MEDICATION(S)]) was administered to Resident #74 on 11/27/21 (3-11 shift) and 11/28/21 (7-3 and 3-11 shift). Resident #74 was admitted to the nursing facility on 10/18/21. diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, patternF761Dec 2, 2021

  Based on observation and staff interviews the facility staff failed to ensure medications were labeled and stored in accordance with currently accepted professional principles in 1 out of 4 facility medication carts and 1 out of 2 medication refrigerators. The facility staff failed to ensure one [MEDICATION(S)] pen and antibiotic eye drop (Neo/poly ointment) were dated once opened. The facility staff failed to ensure a multi-dose vial of PPD vaccine was dated once opened. The findings included: A. On 12/30/21 at approximately 2:20 p.m., the medication cart on Alleghery Unit (cart 1) was inspected with License Practical Nurse (LPN) #4. Stored inside the medication cart was an open [MEDICATION(S)] (insulin) pen and antibiotic eye drop (Neo/poly ointment) without an open date. […]

• No harm, potential for more than minimal, patternF658Aug 19, 2021

  Based on information gleamed during a complaint investigation, staff interviews, clinical record review, and review of facility documents, the facility's staff failed to follow a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #4), in the survey sample. The findings included: Resident #4 was originally admitted to the facility 7/27/21, and was discharged from the facility 8/1/21, after a change in status was observed. Resident # 4's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The five day Prospective Payment System (PPS) Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/1/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 4 out of a possible 15. […]