Potomac Valley Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Potomac Valley Rehabilitation and Healthcare, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Dec 8, 2022

  Based on record review and staff interview, it was determined that the facility staff failed to appropriately assess residents to identify those with an elopement risk, to implement interventions when a resident was identified as an elopement risk, and to monitor, supervise, and search when they were unable to locate the resident. This was evident for 1 (#3) of 3 residents reviewed for wandering. As a result of this deficient practice, a cognitively impaired resident was able to exit the facility at an unknown time and was exposed to temperatures as low as 42 degrees Fahrenheit and rain. A bystander was concerned about the individual sitting on the curb outside their residence and called 911. […]

• No harm, potential for more than minimal, widespreadF657Mar 25, 2025

  Based on interviews and medical record review, it was determined that the facility staff failed to ensure interdisciplinary team (IDT) care plan meetings were conducted and failed to update a care plan after a change in status. This was found to be evident for five (Residents #90, 100, 104, 125 and 40) out of five residents reviewed for care planning specifically, and an additional three (Residents #111, #145 and #3) out of 32 other residents reviewed during the 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. […]

• No harm, potential for more than minimal, widespreadF803Mar 25, 2025

  Based on observations, record review, and interviews, it was determined that the facility failed to ensure that residents were served meals according to a predetermined menu that incorporated the residents' preferences. This deficient practice has the potential to affect all residents. The findings include: 1) While observing the lunch tray line on 3/20/25 at 11:54 AM, the surveyor requested a test tray. The tray contained a meal ticket for Resident #148 that listed food items that were to be served: 1-3 oz BBQ chicken on BUN, 4 oz Calico coleslaw, 1/2 slice lemon cake, 4 oz apple juice, 8 oz milk 2%, 8 oz coffee. However, continued observation failed to show that Resident #148's tray contained 4 oz of coleslaw and 8 oz of 2% milk. […]

• No harm, potential for more than minimal, widespreadF812Mar 25, 2025

  Based on observations, record review, and interviews, it was determined that the facility failed to store food in accordance with professional standards. This deficient practice has the potential to affect all residents. The findings include: An initial tour of the facility's kitchen with the food services supervisor on 3/17/25 at 8:50 AM revealed the following: -An opened container of French salad dressing labeled with the date opened as 2/10/25. Staff indicated that it should only be kept for one month after opening. -Leftover ground sausage links labeled with the date prepared as 3/1/25. The staff stated it was supposed to be kept for a day. - A bag of pancakes was found open without a label indicating its opening date. […]

• No harm, potential for more than minimal, widespreadF838Jan 27, 2022

  Based on facility documentation review and interview it was determined the facility failed to update the facility assessment. This was evident for 2 of 2 days the surveyors were on site during a focused infection control survey and had the potential to affect all residents and staff. The findings include: A review of the Facility Assessment was conducted on 1/27/22 at 8:31 AM. The Facility Assessment is a tool used to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. […]