Inspection Reports for
Village at Rockville
9701 Veirs Drive, Rockville, MD, 20850
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Maryland average
Maryland average: 12.8 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 11, 2024
Visit Reason
The inspection was conducted as a recertification survey including review of complaints and allegations of abuse, failure to respond timely to call bells, failure to provide CPR as ordered, and failure to report and investigate abuse allegations properly.
Complaint Details
The complaint investigation included substantiated findings of abuse against a resident by a nursing assistant who refused assistance and used abusive language. Multiple allegations of abuse were not reported within the required two-hour timeframe. The facility failed to thoroughly investigate abuse allegations, missing key interviews. The failure to provide CPR as ordered was also investigated and cited.
Findings
The facility was found deficient in timely responding to resident call bells, substantiated abuse of a resident by staff, failure to report allegations of abuse within required timeframes, failure to thoroughly investigate abuse allegations, and failure to provide CPR to a resident as instructed by their MOLST form. Corrective actions were implemented for the CPR deficiency.
Deficiencies (5)
F 0558: The facility failed to respond timely when residents called for assistance, with call bell response delays of 42 minutes or longer on multiple occasions.
F 0600: The facility failed to keep a resident free from abuse when a nursing assistant refused to assist a resident back to bed and used inappropriate language.
F 0609: The facility failed to timely report allegations of abuse within two hours as required for multiple incidents and failed to identify and report potential abuse to the administrator.
F 0610: The facility failed to thoroughly investigate allegations of abuse, missing interviews with complainants, residents, and supervisors in the investigation documentation.
F 0678: The facility failed to provide CPR to an unresponsive resident whose MOLST instructed to attempt CPR, resulting in immediate jeopardy to resident health or safety. Corrective actions were implemented and verified.
Report Facts
Complaints reviewed: 6
Residents reviewed for abuse: 21
Residents affected by call bell delay: 1
Residents affected by abuse: 1
Facility reported incidents reviewed: 17
Facility reported incidents with failure to report abuse timely: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GNA Staff #15 | Geriatric Nursing Assistant | Named in substantiated abuse finding for refusing to assist resident and using abusive language |
| Staff #8 | Registered Nurse | Failed to initiate CPR on Resident #137 as instructed by MOLST |
| Staff #9 | RN Nurse Supervisor | Notified about Resident #137 unresponsiveness and DNR status |
| Director of Nursing | Director of Nursing | Interviewed regarding call bell delays, abuse investigations, and CPR failure |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding call bell delays |
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Oct 11, 2024
Visit Reason
The survey was conducted as a recertification survey with complaint investigations and extended survey tasks triggered by identified deficiencies.
Complaint Details
Complaint #MD00206835 was investigated regarding delayed call bell response times for Resident #152, substantiated with documented delays of 42 minutes or more on multiple occasions.
Findings
The facility was found deficient in multiple areas including delayed call bell response, failure to notify providers of lab results, maintenance issues, abuse reporting and investigation, transfer documentation, care planning, CPR provision, medication management, infection control, food safety, and staff training.
Deficiencies (19)
F 0558: Facility failed to respond timely to residents' call bells, with delays of 42 minutes or more documented multiple times for Resident #152.
F 0580: Facility failed to notify a primary care provider of a lab result for Resident #120 indicating a urine specimen was spilled in transit.
F 0584: Facility failed to maintain the environment in good repair, including an unlocked housekeeping closet and drywall damage in resident rooms.
F 0609: Facility failed to timely report allegations of abuse and failed to thoroughly investigate abuse allegations for multiple residents including Resident #33 and #138.
F 0622: Facility failed to include resident care plans with required documentation during transfers for Resident #45.
F 0623: Facility failed to provide timely written notification of resident transfers and reasons to residents and their representatives for Resident #45 and #98.
F 0624: Facility failed to orient, prepare, and document residents' understanding of transfers for Resident #45 and #98.
F 0625: Facility failed to notify residents and representatives in writing of the bed-hold policy upon transfer for Resident #45 and #98.
F 0656: Facility failed to develop and implement comprehensive care plans including measurable goals and non-pharmaceutical interventions for psychotropic medication monitoring for Resident #118 and failed to update care plan to reflect hearing aid use for Resident #120.
F 0678: Facility failed to provide CPR to Resident #137 despite active MOLST orders to attempt CPR, resulting in immediate jeopardy that was later corrected.
F 0689: Facility failed to ensure only licensed staff fed residents; a private duty aide fed Resident #39 without staff intervention.
F 0700: Facility failed to obtain informed consent prior to bed rail use for Residents #23 and #120.
F 0756: Facility failed to ensure pharmacist recommendations were communicated to physicians for Residents #51, #111, and #117.
F 0757: Facility failed to keep Resident #118's drug regimen free from unnecessary medications by lacking clear parameters for PRN constipation medications.
F 0758: Facility failed to adequately monitor Resident #118 for behavior and side effects related to psychotropic medication use.
F 0812: Facility failed to properly store food items to prevent cross contamination, including uncovered salsa and sour cream in kitchen refrigerators.
F 0842: Facility failed to void previous MOLST forms when updated MOLST forms were completed for Residents #10, #114, and #118, resulting in multiple active conflicting orders.
F 0880: Facility failed to use appropriate infection control practices by allowing a Foley catheter bag to lie on the floor for Resident #125.
F 0941: Facility failed to ensure direct care staff had mandatory communication training for 8 staff members reviewed.
Report Facts
Complaints reviewed: 6
Residents reviewed for abuse: 21
Residents reviewed for hospitalization: 3
Residents reviewed for unnecessary medications: 5
Residents reviewed for advanced directives: 11
Staff training records reviewed: 8
Inspection Report
Routine
Deficiencies: 6
Date: Oct 24, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, and facility safety at The Village at Rockville nursing home.
Findings
The facility failed to develop and implement timely and comprehensive care plans for residents, including baseline care plans and plans addressing pressure injury prevention. There were failures in pressure ulcer prevention and care, resulting in an immediate jeopardy that was later abated. Medication management deficiencies included failure to verify family-supplied medications and improper labeling and storage of drugs and biologicals.
Deficiencies (6)
F 0655: The facility failed to develop and implement a complete baseline care plan within 48 hours of a resident's admission, specifically for medication management.
F 0656: The facility failed to develop and implement a comprehensive person-centered care plan addressing clinical and psychological needs for residents, including monitoring medication side effects and communication needs.
F 0657: The facility failed to revise care plans within 7 days of comprehensive assessment to include preventive measures for pressure injuries related to splints and braces.
F 0686: The facility failed to implement preventive measures for pressure injuries in residents at low to moderate risk, resulting in an immediate jeopardy that was abated after corrective actions.
F 0755: The facility failed to ensure accurate acquiring and receiving of medication from authorized sources, including administration of family-supplied medication without verification.
F 0761: The facility failed to label drugs and biologicals according to professional standards and failed to discard expired items, including tuberculosis skin test vials and expired phlebotomy tubes.
Report Facts
Residents reviewed: 45
Residents affected: 3
Residents identified for review: 32
Residents identified as low or moderate risk: 121
Residents reviewed for Braden scale: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Provided admission Braden Scale risk assessment and admission summary for Resident #105 |
| RN #2 | Registered Nurse | Confirmed Resident #105's dependency in all ADLs at admission |
| GNA #3 | Geriatric Nursing Assistant | Reported Resident #105's dependency and incontinence status |
| GNA #6 | Geriatric Nursing Assistant | Reported Resident #105's dependency and incontinence status |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies and medication management |
| Assistant Director of Nursing | Assistant Director of Nursing | Designated facility wound nurse, interviewed regarding pressure injury care and prevention |
| Charge Nurse | Charge Nurse | Identified family-supplied medication and discarded expired phlebotomy tubes |
Inspection Report
Routine
Deficiencies: 10
Date: Jul 19, 2018
Visit Reason
Routine inspection survey conducted to assess compliance with regulatory requirements for nursing home care and facility operations.
Findings
The facility was found to have multiple deficiencies including failure to promote resident self-determination, maintain resident privacy, provide timely written notifications for hospital transfers and bed-hold policies, inaccurate resident assessments, unnecessary drug use, improper medication documentation, unsanitary food storage, unsafe infection control practices, and inadequate screening and training of private duty aides.
Deficiencies (10)
F 0561: Facility staff failed to inform resident #120 of the recommended cardiology follow-up after myocardial infarction discharge.
F 0583: Facility staff failed to maintain privacy by posting care-related signs in resident #104's room without consent.
F 0623: Facility staff failed to provide written notification to residents' representatives and ombudsman about hospital transfers for residents #75, #95, and #155.
F 0625: Facility staff failed to provide written notification of the bed-hold policy to residents or representatives during hospital transfers for residents #32, #75, #95, #129, and #155.
F 0641: Facility failed to complete accurate assessments; residents #96 and #101 had incorrect MDS coding for external catheter and ostomy.
F 0757: Facility failed to ensure resident #96's drug regimen was free from unnecessary antibiotics without documented treatment duration since 09-15-16.
F 0758: Facility failed to document duration for PRN psychotropic medication use for resident #47 beyond the original 14 days.
F 0812: Facility staff failed to store and label opened food packages properly and stored food directly on the floor in the walk-in freezer.
F 0880: Facility staff failed to store oxygen tubing in a plastic bag as ordered, exposing resident #75 to infection risk.
F 0943: Facility failed to ensure private duty aides were screened for abuse or trained on abuse prohibition, risking resident #71's safety.
Report Facts
Residents selected for review: 46
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
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