Rockville Skilled Nursing & Rehabilitation Center,

In the surveyor’s words

From the most serious findings on record at Rockville Skilled Nursing & Rehabilitation Center,, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF658Jun 27, 2025

  Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure services provided or arranged by the facility, as outlined by the comprehensive care plan, met professional standards of quality. This was identified for one (Resident #58) of four residents observed during Medication Administration. Specifically, Resident #58 had a Physician's order for 150 milligrams of Topiramate (a medication to treat migraine headaches) daily. From 6/4/2024 to 6/25/2024, multiple medication nurses did not ensure the resident received the correct dosage of Topiramate 150 milligrams. […]

• No harm, potential for more than minimal, isolatedF755Jun 27, 2025

  Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure it provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. This was identified for one (Resident #58 of four residents reviewed for Medication Administration. Specifically, on 6/3/2024, Resident #58 had a new Physician's order for Topiramate 100 milligram tablet, give 1.5 tablet (for 150 milligrams) one time a day for a diagnosis of headaches. […]

• No harm, potential for more than minimal, isolatedF908Jun 27, 2025

  Based on observation, record review, and interviews during the Recertification Survey initiated on 6/23/2025 and completed on 6/27/2025, the facility did not ensure that it maintained all patient care equipment in a safe operating condition. This was identified for one (Resident #161) of two residents reviewed for Pressure Ulcers. Specifically, Resident #161 had a Stage 3 pressure ulcer (full-thickness skin loss, where the damage extends into the subcutaneous tissue) and had a care plan intervention for the use of an air mattress. […]

• No harm, potential for more than minimal, isolatedF686Dec 22, 2023

  Based on record review and interviews during the Recertification and Abbreviated Survey (Complaint #NY00326729) initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure each resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. This was identified for one (Resident #68) of three residents reviewed for Pressure Ulcers. Specifically, Resident #68 was assessed to be at a moderate risk for developing pressure ulcers. On 8/26/2023 the resident's Physician ordered a wheelchair gel cushion as a pressure relieving device. There was no documented evidence that the resident received the gel cushion until 10/19/2023. […]

• No harm, potential for more than minimal, isolatedF695Dec 22, 2023

  Based on observations, record review, and staff interviews during the Recertification Survey initiated on 12/19/2023 and completed on 12/22/2023, the facility did not ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice. This was identified for one (Resident # 317) of four residents reviewed for Respiratory Care. Specifically, Resident #317 was administered oxygen therapy without a Physician's order since the resident's admission to the facility on [DATE] until 12/19/2023. The finding is: The facility's policy and procedure titled, Oxygen Administration, last revised on 10/20/2023 documented that oxygen use must be documented in the medical record. […]