Inspection Reports for
Bel Pre Healthcare Center
2601 Bel Pre Rd, Silver Spring, MD 20906, Silver Spring, MD, 20906
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
9% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
28
21
14
7
0
Inspection Report
Annual Inspection
Deficiencies: 25
Date: Feb 4, 2025
Visit Reason
Annual recertification survey and inspection of Silver Spring Healthcare Center to assess compliance with healthcare regulations and standards.
Findings
The facility was found to have multiple deficiencies including failure to ensure resident dignity, inadequate accommodation of resident needs, incomplete advance directive documentation, failure to provide beneficiary notices, unsafe and uncomfortable environment, incomplete care plans, lack of routine care plan meetings, inadequate podiatry, vision, and dental services, medication errors, improper medication storage, infection control issues, pest control problems, and unsafe physical environment conditions.
Deficiencies (25)
F 0557: The facility failed to ensure a resident was treated with dignity during medication administration, as staff did not close the door to provide privacy.
F 0558: The facility failed to ensure a resident had access to the call bell, which was repeatedly found on the floor out of reach.
F 0578: The facility failed to ensure a resident was offered information for an Advance Directive, with no documentation found.
F 0582: The facility failed to provide beneficiary notices to residents discharged from Medicare Part A with benefit days remaining.
F 0584: The facility failed to provide a safe, clean, comfortable, and homelike environment, with issues including candy on the floor, broken furniture, and plumbing problems.
F 0656: The facility failed to develop and implement a comprehensive care plan addressing a resident's refusal to wear a palm protector and anticoagulant use.
F 0657: The facility failed to develop complete care plans within 7 days of assessments and failed to hold timely interdisciplinary care plan meetings for multiple residents.
F 0657: The facility failed to hold routine care plan meetings for residents, with several residents reporting no invitations or documentation of meetings.
F 0677: The facility failed to ensure residents received podiatry services for overgrown toenails in a timely manner.
F 0685: The facility failed to provide routine vision services, with a resident placed on a Do Not Treat list due to lack of consent.
F 0688: The facility failed to provide prescribed treatment for limited mobility, including failure to apply a palm protector as ordered.
F 0689: The facility failed to supervise residents who smoked and failed to provide protective devices, resulting in immediate jeopardy that was later abated.
F 0695: The facility failed to maintain respiratory therapy equipment according to professional standards, with unlabeled nebulizer equipment observed.
F 0697: The facility failed to ensure pain medication was administered consistent with physician orders, with medication given at incorrect pain levels.
F 0730: The facility failed to conduct yearly performance reviews for some nursing assistants as required.
F 0756: The facility failed to respond timely to pharmacist recommendations regarding unnecessary medications for a resident.
F 0759: The facility had a medication error rate of 46.42%, including errors in medication administration, dosing, and storage.
F 0761: The facility failed to ensure medications were stored properly, with medications left unsecured and scattered.
F 0791: The facility failed to provide routine dental services, with a resident not receiving dental care for over 3 years due to being on a Do Not Treat list.
F 0812: The facility failed to store and prepare food in a manner that maintains professional food safety standards, including undated opened food packages and contaminated seasonings.
F 0814: The facility failed to ensure proper disposal of garbage and refuse, with debris and used medical gloves scattered around the outdoor dumpster area.
F 0842: The facility failed to maintain complete and accurate medical records, including failure to report taped narcotic blister cards and missing PASRR Level II documentation.
F 0880: The facility failed to implement an effective infection prevention and control program, with cross-contamination of clean and dirty linen in the laundry department and unclean tube feeding poles.
F 0921: The facility failed to maintain a safe, clean, and comfortable environment, with grossly soiled, chipped, and missing ceiling tiles in the laundry department.
F 0925: The facility failed to maintain an effective pest control program, with multiple live and dead roaches observed in the kitchen and dietary areas.
Report Facts
Medication error rate: 46.42
Narcotic count discrepancy: 1
Medication administration errors: 13
Residents reviewed for care planning: 39
Residents affected by smoking supervision deficiency: 7
Ceiling tiles soiled or missing: 4
Roach sightings: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #9 | Registered Nurse Supervisor | Confirmed resident refusal to wear palm protector |
| LPN #31 | Licensed Practical Nurse | Observed medication administration errors and improper medication handling |
| Director of Nursing | Director of Nursing (DON) | Confirmed expectations and deficiencies related to dignity, care plans, medication, and services |
| Business Office Manager | Business Office Manager (BOM) | Discussed beneficiary notification process |
| Social Worker #23 | Social Worker | Discussed advance directives and care plan meetings |
| Unit Manager RN #1 | Unit Manager Registered Nurse | Provided HealthDrive lists and confirmed service issues |
| Certified Dietary Manager | Certified Dietary Manager (CDM) | Observed food storage and pest control issues |
| District Manager | District Manager (DM) | Confirmed pest control and food safety issues |
| Environmental Services Director | Environmental Services Director (EVS) | Discussed laundry and ceiling tile issues |
| Maintenance Assistant #6 | Maintenance Assistant | Acknowledged ceiling tile replacement needs |
| LPN #33 | Licensed Practical Nurse | Observed dignity deficiency and medication administration |
| LPN #34 | Licensed Practical Nurse | Observed call bell and medication storage issues |
| LPN #25 | Licensed Practical Nurse | Provided information on resident appointments |
| RN #13 | Registered Nurse | Participated in narcotic count and medication administration |
| RN #14 | Registered Nurse | Participated in narcotic count and medication administration |
| Executive Director | Executive Director (ED) | Made aware of pain management concerns |
| Laundry Aide #15 | Laundry Aide | Observed folding clean linen near soiled linen entry |
| Laundry Aide #17 | Laundry Aide | Observed transporting soiled linen |
| Staff #9 | Staff | Acknowledged dirty feeding pole and cleaning responsibilities |
| Staff #20 | Staff | Provided medication regimen review documents |
| Regional Clinical RN Director | Regional Clinical RN Director (RCD) | Discussed narcotic blister card policy |
| VPIC | President of Infection Control | Discussed PASRR documentation and infection control |
| VPW | President for Social Work | Discussed care plan meetings |
| Business Office Manager | Business Office Manager (BOM) | Discussed beneficiary notification process |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 4, 2025
Visit Reason
The inspection was conducted as part of the recertification survey and annual review of compliance with nursing home regulations, including investigation of abuse allegations and medication-controlled drug security.
Findings
The facility failed to prevent further abuse and neglect during an ongoing investigation involving Resident #53, and nursing staff did not follow proper procedures for medication-controlled drugs and narcotic security for multiple residents.
Deficiencies (2)
F 0610: The facility failed to prevent further abuse, neglect, exploitation, and mistreatment during an investigation involving Resident #53. The alleged perpetrator was not removed from the schedule pending investigation.
F 0658: The facility staff failed to ensure nursing standards for medication-controlled drugs and security were followed for 4 residents. Narcotic blister cards were taped, and narcotic counts and documentation were not properly completed or reported.
Report Facts
Residents reviewed for abuse: 6
Residents affected by abuse deficiency: 1
Residents reviewed for medication-controlled drugs and security: 4
Narcotic blister card tape spots: 17
Oxycodone tablets discrepancy: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN #19) | Named in abuse allegation and continued working with Resident #53 after incident | |
| Geriatric Nurse Assistants (GNA #26 and #27) | Assisted LPN #19 in alleged abuse incident with Resident #53 | |
| Registered Nurse Supervisor (RN #9) | Interviewed Resident #53 about staff involved in abuse allegation | |
| Director of Nursing (DON) | Interviewed regarding abuse investigation procedures and narcotic count policies | |
| Regional Clinical RN Director (RCD) | Interviewed about narcotic count expectations and reporting taped blister cards | |
| Registered Nurse (RN #13 and RN #14) | Observed during narcotic shift count with documentation discrepancies | |
| Nursing Home Administrator (NHA) | Notified of narcotic count concerns |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Oct 2, 2024
Visit Reason
The inspection was conducted as a complaint survey triggered by allegations of improper code status changes, abuse, neglect, misappropriation of resident belongings, and other quality of care concerns at the facility.
Complaint Details
The complaint investigation was substantiated with findings of multiple deficiencies including improper code status changes without proper documentation, abuse by staff, neglect in care and environment, misappropriation of resident belongings, failure to report and investigate incidents properly, and environmental hazards such as pest infestations and malfunctioning call systems.
Findings
The facility was found deficient in multiple areas including failure to properly identify and document residents' code status and surrogate authority, failure to maintain a safe and clean environment, failure to protect residents from abuse and neglect, failure to prevent loss or theft of resident belongings, failure to conduct thorough investigations, failure to provide appropriate foot care and ADL assistance, failure to ensure timely physician discharge summaries, malfunctioning call systems in resident bathrooms, and an ineffective pest control program.
Deficiencies (12)
F578: The facility failed to accurately identify a resident's health status and representative to change code status, lacking advanced directive documentation and proper certification for surrogate decision making.
F584: The facility failed to maintain a clean, safe, comfortable, and homelike environment, with multiple physical damages, unsanitary conditions, and safety hazards observed in resident rooms, bathrooms, hallways, and kitchen.
F600: The facility failed to protect residents from physical abuse by staff, including improper transfers causing pain and confirmed incidents of staff hitting residents.
F602: The facility failed to prevent loss or theft of resident belongings and failed to maintain accurate inventories or conduct proper investigations related to missing items.
F609: The facility failed to timely report alleged misappropriation of resident belongings to the State Agency and failed to conduct thorough investigations of abuse and misappropriation reports.
F610: The facility failed to respond appropriately to alleged violations by not conducting thorough investigations of abuse and misappropriation incidents involving multiple residents.
F658: The facility nursing staff failed to report a resident's injury to a provider, resulting in delayed recognition and response to a bruise on a resident's knee.
F677: The facility failed to provide adequate care and assistance for activities of daily living for a dependent resident, with documented lack of care and treatment on multiple days.
F687: The facility failed to ensure diabetic residents received proper foot care and treatment, with no evidence that a resident was seen by a podiatrist as ordered.
F712: The facility failed to have a timely and accurate physician discharge summary for a discharged resident, with the summary inaccurately stating the resident was seen on the date of the note.
F919: The facility failed to ensure a functioning call system in resident bathrooms and bathing areas, with call bell cords out of reach and call bell indicators not working properly in multiple bathrooms.
F925: The facility failed to maintain an effective pest control program, with ongoing roach and mouse infestations documented since 2022 and observed during the survey in resident rooms and kitchen areas.
Report Facts
Residents reviewed: 41
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Resident rooms observed: 2
Pest control records reviewed: 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff #1 | Attending Physician | Acknowledged changing MOLST and lack of awareness of policies regarding surrogate authority |
| GNA #15 | Failed to use gait belt during transfer causing resident pain; suspended and retrained | |
| Agency GNA #16 | Observed hitting resident #28; placed on do not return list | |
| Director of Nursing | DON | Confirmed abuse findings, failure to report and investigate incidents, and other deficiencies |
| Staff #10 | Licensed Practical Nurse | Interviewed regarding improper storage and standing water in resident room |
| Staff #11 | Laundry Staff | Responsible for labeling resident clothing if needed |
| Staff #12 | Laundry Supervisor | Interviewed about inventory of resident belongings |
| Staff #4 | Licensed Practical Nurse | Interviewed about location and updating of resident personal effects inventory |
| Staff #5 | Regional Nurse | Provided electronic personal effects inventory and confirmed lack of podiatry care |
| Staff #26 | Dietary Aid | Interviewed about dry storage cleaning and pest sightings |
| Staff #27 | Culinary Director | Interviewed about pest control reporting and kitchen conditions |
| Staff #7 | Maintenance Director | Participated in rounds and acknowledged facility concerns |
| Staff #8 | Maintenance Assistant | Participated in rounds and acknowledged facility concerns |
| LPN #19 | Licensed Practical Nurse | Failed to report resident injury; issued teachable moment notice and re-educated |
| NP #20 | Nurse Practitioner | Reported failure to report resident injury |
Inspection Report
Deficiencies: 7
Date: Feb 3, 2020
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding nursing home operations, including resident care, notification requirements, care planning, professional standards, outside services, medical record documentation, quality assurance, and smoking policies.
Findings
The facility was found deficient in multiple areas including failure to timely notify residents of Medicare non-coverage, incomplete care plan conferences, failure to meet nursing standards for wound care and pain management, inadequate coordination of outside professional services, incomplete clinical documentation, failure to meet Quality Assessment and Assurance committee requirements, and inconsistent implementation of smoking policies.
Deficiencies (7)
F 0582: The facility failed to provide timely Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage to Resident #30 as required.
F 0657: The facility failed to conduct timely quarterly care plan conferences with Resident #72 as required.
F 0658: The facility failed to ensure nursing standards of practice for Residents #20 and #245, including delayed physician contact for wound care and lack of pain assessment documentation.
F 0840: The facility failed to ensure Resident #47 received outside oncology services due to unresolved insurance issues and poor communication.
F 0842: The facility failed to maintain complete and accessible clinical documentation for Residents #20 and #79, including missing hospice collaboration notes and physician visit records.
F 0868: The facility failed to ensure the Quality Assessment and Assurance committee met at least quarterly with required members present.
F 0926: The facility failed to consistently implement its smoking policy for Residents #10, #21, and #69, including improper designation of smoker status and noncompliance with smoking material controls.
Report Facts
Residents selected for review: 22
Dates of physician or nurse practitioner visits missing: 24
QAA meeting dates missing: 2
Smoking assessments reviewed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Work | Interviewed regarding failure to conduct care planning conferences with Resident #72 | |
| Director of Nursing | Interviewed regarding multiple deficiencies including wound care, pain management, hospice collaboration, and smoking policy | |
| LPN #1 | Licensed Practical Nurse | Named in finding related to lack of pain assessment documentation for Resident #245 |
| Lower Level Unit Manager | Interviewed regarding wound care treatment for Resident #20 | |
| Upper Level Unit Manager | Interviewed regarding oncology appointment scheduling and insurance issues for Resident #47 | |
| Business Office Manager | Interviewed regarding insurance issues related to Resident #47's oncology appointment | |
| Hospice RN #7 | Hospice Registered Nurse | Interviewed regarding hospice collaboration documentation for Resident #20 |
| Activity Director | Interviewed regarding smoking materials control and resident compliance |
Inspection Report
Annual Inspection
Deficiencies: 10
Date: Mar 29, 2019
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided at Silver Spring Healthcare Center.
Findings
The facility was found to have multiple deficiencies including failure to convey resident funds upon death, failure to notify representatives of treatment changes, incomplete care plan revisions, medication administration errors, inadequate nurse aide performance reviews, unlabeled medications, inaccurate documentation of elopement risk, ineffective pain management documentation, and nonfunctional call light systems in resident bathrooms.
Deficiencies (10)
F 0569: The facility failed to convey resident #189's remaining personal funds to the estate within 30 days of death.
F 0580: The facility failed to notify resident #52's representative of the discontinuation of the wander guard device.
F 0623: The facility failed to provide written notification to resident #45 or representative before hospital transfer.
F 0657: The facility failed to revise care plans after assessments and ensure resident participation in care plan meetings for 4 residents.
F 0658: The facility failed to document blood sugar results and clarify unclear medication orders for residents #13 and #58.
F 0684: The facility failed to follow physician orders for pain medication administration for residents #7 and #68 and failed to discontinue a wander guard as ordered for resident #52.
F 0730: The facility failed to complete annual performance reviews for nurse aide #1.
F 0761: The facility failed to label an opened bottle of 1% Xylocaine in medication storage.
F 0842: The facility failed to maintain accurate documentation of elopement risk and pain management effectiveness for residents #21, #7, and #68.
F 0919: The facility failed to ensure functional call light systems in 2 of 10 resident bathrooms on the upper level unit.
Report Facts
Residents selected for beneficiary protection notification review: 4
Residents selected for notification of changes review: 1
Residents selected for hospitalization review: 2
Residents selected for care plan review: 25
Residents selected for standard of practice review: 25
Residents selected for assessment review: 25
Nurse aides selected for performance review check: 5
Medication storage carts inspected: 4
Bathrooms inspected for call light functionality: 10
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