Bridgepoint Subacute And Rehab Capitol Hill

Based on record reviews and staff interviews, facility staff failed to show documented evidence of an effective training program for all staff, which includes, at a minimum, training on behavioral health care and services for its residents. The findings included: On 05/05/25, the facility's education and training records for were reviewed as part of an extended survey. The facility provided a binder from the educator that included the education and training records for staff in the facility for review. The binder showed no documented evidence of an effective training program for all staff, which included, at a minimum, training on behavioral health care and services for its residents. During a face-to-face interview on 05/05/25 at 9:15 AM, Employee #48/ Regional Director of Operations, stated that the behavioral health care and services for residents is usually completed during staff orientation and as part of the staff skills fair training that the facility has annually. Employee #48, then reviewed the facility's staff education and training binder, and the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, five (5) of 49 residents sampled, facility staff failed to have documented evidence that they provided information to the residents and/or their representatives (RP) regarding their right to formulate or refuse an advanced directive. Residents #87, #56, #91, #74, and #73. The findings included: Review of the facility's Advanced Directives policy dated 05/24/24 documented: - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. - If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. - If the resident indicates that he or she has not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 5. Resident #91 was admitted to the facility on [DATE] with multiple diagnoses that included: Interstitial Pulmonary Disease, Type 2 Diabetes Mellitus and Chronic Respiratory Failure. Review of the resident's medical record revealed the following: An admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 13, indicating intact cognitive response. Physician's orders dated 02/10/15 directed, Established [central] line - Change dressing Q (every) 7 days, every night shift every Monday for IV-line care; Change dressing as needed if not intact or soiled as needed for IV care; Observe insertion site every shift for redness, warmth, swelling, drainage, coldness or irritation, every shift for IV care. Review of the April 2025 Treatment Administration Record (TAR) showed that on 04/07/25, facility staff documented a check mark and their initials to indicate that the resident's central IV-line dressing was changed during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and resident and staff interview, the Interdisciplinary Team (IDT) failed ensure a resident was safe to self-administer an Albuterol inhaler for one (1) of 1 sampled resident who self-administer medicine. (Resident #46). The findings included: Resident #46 was admitted on [DATE] with multiple diagnoses including Pulmonary Chronic Obstructive Disease, Bipolar, Schizophrenia, and Anxiety. A policy titled, Self-Administering Medications with a review date of 05/24/24 instructed, Residents have the right to self-administer medications if the interdispilinary team has determined that it is clincally appropiate and safe for the resident to do so . The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clincally appropiate for the resident .the nursing staff will determine who will be responsible (the resident or nursing staff) for document that medications were taken .medications must be stored in a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff and family interviews, the facility failed to have documented evidence that verbal abuse of resident did not occur after receiving an allegation of staff-to-resident verbal abuse for one (1) of 1 sampled residents. (Resident #158) The findings included: Resident #158 was admitted on [DATE] with multiple diagnoses including Altered Mental Status, Muscle Weakness, and Psychotic Disorder. During a telephone interview related to different concern (Complaint DC~12827) on 04/25/25 at approximately 10 AM, the resident daughter (complainant) stated that Employee #39 (CNA) said, My mom was pistol in front of my mom. After the employee said my mom was afraid and wanted to go home. The resident's daughter then said, I told her [Employee #39] that I would not tolerate any mistreatment of my mom. And then the employee said that she could tell I was from the streets. Additionally, the resident's daughter said that she made the Administrator aware and she never saw Employee #39 again. It…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews for one (1) of 49 sampled residents, facility staff failed to provide documented evidence that one resident's bedrails were not being used as a restraint for a non-ambulatory, cognitively impaired resident who required extensive assistance with bed mobility and transfers. Resident #308. The findings included: A facility document titled 'Physical Restraint Application' with a review date of October 2010 documented the following: Definition - Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body Documentation - The following information should be recorded in the resident's medical record: 1. The date and time the restraint was applied. 2. The name and title of the individual(s) who applied the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for two (2) of 49 sampled residents, facility staff failed to report an incident of alleged staff-to-resident verbal abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Residents #62 and #40 The findings included: A facility policy titled 'Abuse Investigation and Reporting' with a review date of 05/24/24 documented the following: Policy Statement - All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting - 2. An alleged violation of abuse, neglect,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for two (2) of 49 residents sampled, facility staff failed to have documented evidence that they conducted thorough investigations for one resident's missing cellphone and one resident's allegation of staff-to resident verbal abuse. Residents #87 and #81. The findings included: Review of the facility's Abuse Investigation and Reporting policy dated 05/24/24 documented: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. -The role of the investigator includes interviewing staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. 1. Facility staff failed to conduct a thorough investigation for Resident #87's missing cellphone. Resident #87 was admitted to the facility on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for one (1) of 49 sampled residents, the facility staff failed to review the comprehensive person-centered care plan as required. (Resident #38) The findings included: Resident #38 was admitted on [DATE] with multiple medical diagnoses that included Dysphagia following Cerebral Infarction, Hemiplegia and Oropharyngeal Disease. A review of medical records for Resident #38 revealed that there were no care plans reviewed and implemented after MDS assessments were completed on the following dates: 04/01/24 (Quarterly), 07/02/24 (Annual) and 11/29/24 (Quarterly). During a face-to-face interview on 04/24/25 at approximately 2:50pm, Employee #18 (Director of Social Work) stated that the resident's care plans were not reviewed by the Inter-Disciplinary Team (IDT) after the quarterly MDS dated [DATE] and 11/29/24, the annual MDS dated [DATE]. Cross Reference 22B DCMR Section 3210.4

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, for two (2) of 49 residents sampled, facility staff failed to ensure that residents, who are unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Residents #87, and #86. The findings included: Review of the facility's Activities of Daily Living (ADLs), Supporting policy dated 05/24/24 documented: - Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. - Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: hygiene (bathing, dressing, grooming, and oral care). 1. Facility staff failed to ensure that Resident #87, who is unable to carry out activities of daily living, received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for two (2) of 49 sampled resident's the facility's staff failed to follow: (1) Professional Standards of Practice when preparing to administer a subcutaneous injection as evidenced by Employee #16 prepared who a Heparin [anticoagulant] injection using an intramuscular (IM) gauge and length needle instead of a subcutaneous (SQ) gauge and length needle. It should be noted that the surveyor intervened before Employee #16 administered Heparin with the IM gauge and length needle. And (2) failure to follow physician's orders and care plan for turning and repositioning Resident #74 every two (2) hours. The Findings included: Resident # 75 was admitted on [DATE]. The resident had a history of Deep Vein Thrombosis (DVT). According to Pfizer medication information leaflet titled, Heparin Sodium Injection, Solution Hospira, Inc. with a revision date of 05/2021 documented in part, Administer Heparin Sodium Injection by intermittent intravenous injection, intravenous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, the facility staff failed to provide a resident with water flushes via Percutaneous Endoscopic Gastrostomy (PEG) tube as prescribed for one (1) of 49 sampled residents. (Resident #38) The findings included: Resident #38 was admitted on [DATE] with multiple medical diagnoses that included Dysphagia following Cerebral Infarction and Gastrostomy Tube. A care plan with a review date of 09/13/24 documented in part, Focus - [Reside#38] requires tube feeding related to Dysphagia .Interventions -The resident is dependent with [gastrostomy] tube feeding and water flushes . A physician order dated 02/12/25 instructed, hydration water flushes 300 milliliters every four (4) hours via gastrostomy tube. A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented in part that the resident had a Brief Interview for Mental Status (BIMS) summary score of 01, indicating that the resident cognitive status was severely impaired. The resident was also coded for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, for two (2) of 49 residents sampled, facility staff failed to ensure that the residents received care and services, consistent with professional standards of practice, for their central intravenous (IV) lines. Residents' #91 and #53. The findings included: Review of the facility's Central Venous Catheter Dressing Changes dated 05/24/24 documented: - The purpose of this procedure is to prevent catheter-related infections - After the original insertion of CVAD (central venous access device), change transparent semi-permeable membrane (TSM) dressings at least every 5-7 days and PRN (as needed). According to the National Institute of Health (NIH): - Per Centers for Disease Control (CDC) guidelines and nursing standards of practice, central line dressings should be changed at a minimum of every seven (7) days and as needed. - Label the dressing with the date, time, and your initials, as well as the date the dressing should be changed again. - Labeling is a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of 49 residents sampled, facility staff failed to ensure that Resident #53's attending physician evaluated his total program of care as evidenced by failing to have documented evidence that the physician reviewed the pharmacist recommendations for four (4) months. The findings included: Review of the facility's Medication Regimen Review policy dated 06/21/17 documented: - The pharmacist must report any irregularities to the attending physician, the facility's Medical Director, and Director of Nursing (DON), and these reports must be acted upon in a manner that meets the needs of the residents. - For non-urgent recommendations, the facility, and attending physician must address the recommendation(s) in a timely manner, no later than their next routine visit. Resident #53 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Pain, Schizophrenia, Anxiety Disorder, and Anoxic Brain Injury. Review of the resident's medical record…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, for two (2) of 49 residents, sampled, facility staff failed to demonstrate appropriate competencies and skills sets to provide safe nursing services. Residents #73 and #209. The findings included: Review of the facility's Change in a Resident's Condition or Status policy dated 05/24/24 documented: - The nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition; need to alter the resident's medical treatment significantly; need to transfer the resident to a hospital/treatment center. - Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR Communication Form. 1. Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included: Encounter for Attention…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interview, the facility's staff failed to ensure a resident's medication recently received from pharmacy was available for administration for one (1) of 49 sampled residents. (Resident #75) The findings included: Resident #75 was admitted on [DATE] with multiple diagnoses including Epilepsy, Spastic Quadriplegia, Ventilator Dependent and Gastrostomy Tube. A policy titled, Medication Ordering and Receipt with a review date of 01/03/25 instructed, The nurse .will sign the packing slip .indicating the correct medication has been delivered to the correct medication cart . A physician's order dated 03/31/25 instructed, Levetiriacetam (anti-epileptic drug) 100 milligrams/milliters solution administer 10 millitiers (1000 milligrams) via gastrostomy tube every 12 hours to prevent seizures. A pharmacy request form dated 04/11/25 revealed that the facility reordered Resident #75's Levetiracetam 100mg/ml solution on 04/11/25 and it was delivered to the facility on that same…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of 49 residents sampled, facility staff failed to have documented evidence that the attending physician reviewed and acted upon identified irregularities noted by the pharmacist. Resident #53. The findings included: Review of the facility's Medication Regimen Review policy dated 06/21/17 documented: - The pharmacist must report any irregularities to the attending physician, the facility's Medical Director, and Director of Nursing (DON), and these reports must be acted upon in a manner that meets the needs of the residents. - For non-urgent recommendations, the facility, and attending physician must address the recommendation(s) in a timely manner, no later than their next routine visit. Resident #53 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Pain, Schizophrenia, Anxiety Disorder, and Anoxic Brain Injury. Review of the resident's medical record revealed the following: Physician's orders dated 10/29/24 that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interview, facility staff failed to ensure that the medication error rate was 5% or less. Subsequently, the facility had a 16% medication error rate. The findings included: During eight (8) medication administration observations conducted from 04/15/25 through 04/25/25 showed (4) errors out 25 opportunities. The medication error rate was 16%. During a face-to-face interview on 04/25/25 at approximately 3PM, Employee #2 stated that staff are provided with education on medication administration and medication management. She will ensure they receive additional education. Cross Reference F554, F684, F755, F761, and F880

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, facility staff failed to ensure safe and secure storage of residents' medications as evidenced by storing: three (3) opened and undated vials of insulin for three residents in the medication refrigerator, two, opened, expired insulin vials for two (2) residents in the medication refrigerator, and by failing to remove one Resident's insulin pen from the medication refrigerator after the Resident was discharged from the facility. Residents #9, # 64, #77, #209, and #259. The findings included: 1.On 04/23/25 at 12:03 PM, during an observation of the 5th Floor Medication Storage Room, one opened, expired vial of Humalog Mix 75/25 insulin for Resident #9 was observed in the medication room refrigerator. A handwritten date was observed in the box that the vial of insulin came in, indicating that the insulin vial had been opened on 03/20/25. Per manufacturers' ([NAME] Lilly) the guidelines for Humalog Mix 75/25 (https://uspl.lilly.com/humalog7525.html#ug),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record reviews, and staff interviews, the facility staff failed to ensure that food was prepared in a form designed to meet the individual needs for one (1) of six (6) sampled residents who was prescribed a mechanically altered diet. Subsequently, Resident #38 was served roast beef that was not mechanically altered to bite size as prescribed. (Resident #38) The findings included: Resident #38 was admitted on [DATE] with multiple medical diagnoses that included Dysphagia following Cerebral Infarction, Oropharyngeal Disease, Gastrostomy Tube, Gastro-Espohgeal Reflux, and Loss of Teeth. A physician's order dated 02/12/25 instructed Pleasure diet -soft and bite sized texture .upright 90-degree positioning, assist feed, small bites/sips, slow rate . Please note: This is a pleasure diet, the resident received gastrostomy tube feeding daily to meet nutritional needs, per physician order. A quarterly Minimum Data Set, dated [DATE] documented in part that the resident had a Brief Interview for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interview, during a tour of the kitchen on April 13, 2025, at approximately 6:30 AM, facility staff failed to store and distribute food under sanitary condition as evidenced by one (1) of one (1) open bag of shredded carrots that was stored in the walk-in freezer undated, two (2) of five (5) torn air/strip curtains in one (1) of one (1) walk-in refrigerator/freezer unit, six (6) of six (6) ceiling lights above the three-compartment sink that were soiled with dust, one (1) of two (2) open eyewash solution bottle that was stored by the tray line for use, one (1) of two (2) garbage disposals that was inoperative , two (2) of two steamers with an 'out of service since May 8, 2023' sign, one (1) of two food warmers that has been inoperative since June 1, 2023. In the dry storage room, one (1) of five (5) 33.8 fluid ounces of Twocal, calorie & protein nutritional drink expired as of April 1, 2025, three (3) of 18 celling lights were missing a light bulb tube guard, and a ceiling tile that had been removed, needed to be replaced. The findings included: 1. An open…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on a review of the facility's records and a staff interview, the facility failed to comply with the State Regulation (22B DCMR sect. 3211.5) for daily staffing ratios, as evidenced by not providing the minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day, with at least six tenths (0.6) hours being provided by a registered nurse for seven (7) of 35 sampled days. The findings included: A review of the facility's daily staffing sheets revealed the following: On 10/19/24 the facility's resident census was 110. In addition, residents received 3.9 hours of direct nursing care. On 11/24/24 the facility's resident census was 105. In addition, residents received 3.8 hours of direct nursing care. On 12/21/24 the facility's resident census was 110. In addition, residents received 3.3 hours of direct nursing care with 0.50 of those hours being provided by a registered nurse. On 12/22/24 the facility's resident census was 110. In addition, residents received 3.6 hours of direct nursing care. On 12/29/24 the facility's resident census was 109.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 49 residents sampled, facility staff failed to have accurate documentation in Resident #209's medical record. The findings included: Resident #209 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Respiratory Failure, Anoxic Brain Injury, and Metabolic Encephalopathy. Review of the resident's medical record revealed the following: 04/21/25 at 5:59 PM Situation Background Assessment and Request (SBAR): - Situation - Tachycardia with a pulse of 135 and an oxygen saturation of 85% - Comments: In the morning the resident had a pulse of 135 and his oxygen saturation was 85%, I informed Nurse Practitioner (NP), and she said to call 9-1-1, the resident was transferred via Emergency Medical Services to [Hospital name]. A physician's order dated 04/21/25 directed, Transfer to hospital. Review of the Medication and Treatment Administration Record for April 2025 showed that on 04/21/25, night shift (7:00 PM - 7:00 AM), the nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interview, for one (1) of two (2) sampled residents that were administered insulin, the facility's staff failed to follow acceptable Infection Control practices. As a result Employee #47 (RN) failed to perform hand hygiene after administering insulin. (Resident #38) Resident #38 was admitted on [DATE] with multiple diagnoses including Type 2 Diabetes Mellitus. A policy titled, Subcutaneous Injections with a review dated of 05/24/24 instructed on part, Put on gloves .Select appropriate injection site . slowly inject medications .with drawn needle quickly .discard equipment .remove gloves .perform hand antiseptic [hand hygiene] . A physician order dated 02/12/25 instructed, Humalog 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 2unit; 151 - 200 = 4unit; 201 - 250 = 6unit; 251 - 300 = 8unit; 301 - 350 = 10unit; 351 - 400 = 12unit Call Md If Blood sugar is less than 60mg/dl (milligram per deciliter) or more than 400mg/dl, subcutaneously every 6 hours for Type 2…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, and interview, facility staff failed to ensure that the environment remains free of pest as evidenced by three (3) of three (3) mouse traps that were observed around the cook line, one (1) of one (1)mouse trap and mouse droppings in the dishwashing machine room, and flying pest in the three-compartment sink area. The findings included: 1. Three (3) of three (3) mouse traps were observed around the cook line, behind one (1) of one (1) grill and one (1) of one (1) gas stove, and one (1) of one (1) mouse trap and mouse droppings were seen in a corner area of the dishwashing machine room. 2. Flying insects that appear to be gnats were observed in the area where the three-compartment sink is located, and sporadically throughout the kitchen. Employee #37 acknowledged the findings during a face-to-face interview on April 17, 2025, at approximately 3:00 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for two (2) of 42 sampled residents, facility staff failed to implement its policy as evidenced by: 1) not having documented evidence they conducted a background check or that an employee received abuse education and 2) not removing the alleged perpetrator (facility staff) from the facility to protect the alleged victim (resident) from further abuse pending an investigation. Residents' #70 and #31. The findings included: Review of the facility policy Abuse Prevention Program revised on 12/01/22 documented: - As part of the resident abuse prevention, the administration will conduct employee background checks - Require staff training/orientation programs that include such topics as abuse preventions, identification, and reporting abuse 1. Facility staff failed to implement its policy by not having documented evidence they conducted a background check or that an employee received abuse education. Resident #70 was admitted to the facility on [DATE] with multiple diagnoses…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for three (3) out of 42 sampled residents, the facility staff failed to provide written information to the resident or resident representative that stated the duration of the State Agency's bed-hold policy before the facility transferred the Resident to the hospital. Residents' #2, #310, and #34. The findings included: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Apraxia, Contracture of the Left Hand, Presence of an Artificial Eye, and Obsessive Compulsive Disorder. A review of Resident #2's medical record revealed: Resident #2's face sheet indicated that her primary Payor was Medicaid. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that the facility staff coded the Resident in the following manner: Brief Interview for Mental Status (BIMS) score of, 02, indicating severely impaired cognition. An SBAR (Situation, Background, Assessment and Recommendation/Request) Communication Form…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interview for one (1) of 42 sampled residents, the facility staff failed to develop a resident's person-centered comprehensive care plan with goals and approaches for the use of an indwelling Foley catheter. Resident #54. The findings included: Resident #54 was admitted to the facility on [DATE]. The resident had a history of Cerebral Palsy, Asthma, Seizure, Anemia, Atrial Fibrillation, and Sepsis. A review of a physician's order dated 11/27/23 at 1900 [7:00 PM] directed: Foley catheter care q shift every shift. A review of an admission Minimum Data Set (MDS) assessment dated [DATE] revealed that facility staff coded Resident #54 had a severe cognitive impairment. The resident was dependent on staff for bed mobility, transfers, toilet use and the resident had an indwelling catheter. A review of Resident #54's comprehensive care plans lacked documented evidence that the facility staff developed a care plan with goals and approaches for his use of an indwelling urinary catheter.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and staff interviews, for one (1) of 42 sampled residents, the facility's staff failed to ensure Resident #362 was provided appropriate care to prevent the resident's suprapubic catheter from becoming dislodged during care. Resident #362. The findings included: Resident #362 was admitted to the facility on [DATE] with multiple diagnoses including Functional Quadriplegia, Neuromuscular Dysfunctional Bladder, Urogenital Implants, and Calculus Ureter. It should be noted the resident was discharged home on [DATE]. A review of a care plan dated 08/29/22 documented the following but not limited to: Focus Area - [Resident's name] has an indwelling suprapubic catheter (Neurogenic bladder). Goal - [Resident's name] will be free from catheter-related trauma through review date. Interventions -Catheter: [Resident's name] has 24fr indwelling suprapubic Catheter. Position catheter bag and tubing below the level of the bladder and away from entrance room door. -Check tubing for kinks each shift.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, resident and staff interview, for one (1) of 42 sampled residents, Employee #5 (Licensed Practical Nurse/LPN), failed to ensure that Resident #46 received effective pain management in accordance with the physician's orders and the comprehensive care plan. The findings included: Resident #46 was admitted to the facility on [DATE] with diagnoses that included: Chronic Pain Syndrome, Chronic Obstructive Pulmonary Disease (COPD) and Retention of Urine. A physician's order dated 11/02/23 that directed, Acetaminophen (pain reliever) Tablet 325 MG (milligrams), give 2 tablets by mouth every 6 hours as needed for pain, do not exceed 3-4gm (grams) in 24 hours. A care plan focus area: [Resident #46] has acute pain r/t (related to) medical procedure abdominal surgical site. Date Initiated: 11/02/2023. Interventions included: - Administer analgesia medication as per orders - Give 1/2 (half) hour before treatments or care - Anticipate the resident's need for pain relief and respond immediately to any…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on one (1) of five (5) observations and staff interview, facility staff failed to demonstrate competency to provide appropriate nursing services to assure resident safety. The findings included: According to the National Library of Medicine- National Center for Biotechnology Information, - If multiple medications must be administered enterally, they should be administered separately, ideally after flushing the feeding tube with 5-10 mL of water, due to the unpredictable stability and compatibility of crushed drug mixtures and the potential for serious drug-drug interactions - Guidance documents from CMS (Centers for Medicare and Medicaid Services) state that the crushed medications should not be combined and given all at once via feeding tube https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10511598/ According to the Long-Term Care Nursing: Medication Pass, - Do not, under any circumstances, try to pre-pour medications to save time - Pre-pouring medications are against regulations - In addition, it increases the risk of making mistakes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on one (1) of five (5) observations, record review and staff interviews, facility staff failed to ensure that the system to account for the reconciliation of controlled medications was followed. The findings included: During an observation on 01/11/24 at 8:44 AM of Medication Cart B on the 5th Floor with Employee #7 (Licensed Practical Nurse/LPN) the following was noted on the January 2024 Controlled Medication Shift Change Log: - 01/01/24 - 7:00 AM count correct- left blank; signature off-going nurse- left blank; signature on-coming nurse- left blank - 01/01/24 - 7:00 PM count correct- left blank; signature off-going nurse- left blank; - 01/02/24 - 7:00 AM count correct- left blank; signature off-going nurse- left blank; - 01/06/24 - 7:00 AM - 7:00 PM count correct- left blank - No entry for 01/06/24 7:00 PM - 7:00 AM - 01/07/24 - 7:00 AM - 7:00 PM count correct- left blank - 01/07/24 - 7:00 PM - 7:00 AM count correct- left blank - 01/08/24 - 7:00 AM - 7:00 PM count correct- left blank; signature on-coming nurse- left blank - 01/08/24 - 7:00 PM - 7:00 AM count correct- left…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and staff interview, the facility failed to serve cold food (pineapples and pears) at or below 41 degrees Fahrenheit for two (2) of 2 opportunities. The findings included: On 01/11/24 at 1:19 PM, a test tray on the 4th floor revealed a cup of pineapples that had a temperature of 51 degrees Fahrenheit. During a face-to-face interview on 01/11/24 at 1:20 PM, Employee #18 (Chef) acknowledged the findings. On 01/12/24 at 12:59PM, a test tray on the 4th floor revealed a cup of pears that had a temperature of 53 degrees Fahrenheit. During a face-to-face interview on 01/12/24 at 1:00 PM, Employee #18 acknowledged the findings. During a face-to-face interview on 01/12/24 at 1:30 PM, Employee #19 (Food Service Director) stated that moving forward they will order cooling bowls with lids to serve cold food.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of 42 sampled residents, facility staff failed to operate and provide services in compliance with applicable State regulations regarding professionals providing services in the facility. Resident #70. The findings included: According to 22B DCMR sec. 3203.7, Each administrative record shall be retained for at least five (5) years from the date of creation. Resident #70 was admitted to the facility on [DATE] with multiple diagnoses that included: Quadriplegia, Spinal Stenosis and Muscle Weakness. An admission Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition. A Facility Reported Incident (FRI), DC~11412, submitted to the State Agency on 12/27/22 documented: [Resident #70] reported to the nursing supervisor that the assigned RN (Registered Nurse) screamed at him because he refused to be turned. During an onsite investigation and review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, for one of eleven (11) sampled residents, facility staff failed to report the results of its investigation for an incident involving resident-to-resident verbal abuse to the State agency within five (5) working days of the incident. Residents #3 and #5. The findings included: Review of the facility's policy entitled Abuse Investigation and Reportingdocumented: The Administrator or his/her designee will provide the appropriate agencies or individual .with a written report of the findings of the investigation within five (5) working days of the occurrence of the incident. 1. Resident #5 was admitted to the facility on [DATE] with diagnoses including Metabolic Encephalopathy, Chronic Respiratory Failure, Hemiplegia, Muscle Weakness, Adjustment Disorder with Mixed Anxiety and Depressed Mood. Review of Resident #5's medical record revealed the following: A physician's order dated 08/18/22 directed: Quetiapine Fumarate 25 mg. Give 0.5 mg tablet by mouth every 12 hours for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and resident interviews for (1) of eleven sampled residents, facility staff failed to update Resident #3's care plan interventions after the Resident had another verbal altercation with a second resident (Resident #5). The findings included: 1.Resident #7 and Resident #3 had a verbal altercation on 04/09/23. A. Resident #7 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Type 2 Diabetes Mellitus, Chronic Respiratory Failure, Tracheostomy, Gastrostomy, Psychotic Disorder, Depression, Anxiety, and Bipolar Disorder. Review of Resident #7's medical record revealed the following: An admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded the Resident as having a Brief Interview for Mental Status (BIMS) Summary Score of, 8, indicating the Resident had moderately impaired cognition. In addition, facility staff coded the Resident as rejecting care and having verbal behavioral symptoms directed toward others (e.g.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews of (1) of eleven sampled residents, facility staff sat at the nurse's station and failed to respond to a resident's room while the ventilator alarmed continuously to alert staff of a ventilator emergency when the HME (heat moisture exchange) tubing had dislodged from the resident's tracheostomy collar for longer than one minute. (Resident #8). The findings included: Resident #8 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Respiratory Failure, Tracheostomy, Ventilator Dependent, Dementia, Anxiety, Cerebral Vascular Accident with Left Hemiparesis, Sigmoid Volvulus, Bowel Resection, Gastrostomy, Congestive Heart Failure and Morbid Obesity. A Physician order dated 02/11/21 documented, Trach (tracheostomy) care and suctioning q (every) shift and PRN (as needed) by Nursing/RT (Respiratory Therapist). A Care Plan focus area dated 09/07/21 documented, [Resident's name] has an ADL self-care performance, incontinence deficit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interview, for four (4) of nine (9) sampled residents, facility staff failed to provide the residents, or their representatives, with written information that specified the duration of the state bed-hold policy before transfer to the hospital. Residents' #2, #3, #5 and #9. The findings included: Review of the facility's Bed-Holds and Return Policy documented that prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. 1. Resident #2 admitted to the facility on [DATE] with multiple diagnoses that included: Muscle Wasting and Atrophy, Amyotrophic Lateral Sclerosis, Respiratory Failure and Dependence on Respirator (Ventilator). Review of Resident #2's medical record revealed the following: A face sheet that documented the resident's spouse as their responsible party. An admission Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded: a Brief Interview for Mental Status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to immediately (within 2 hours) report an allegation of employee-to-resident physical abuse to the State Agency. Resident #7. The findings included: Review of the facility policy Abuse Investigation and Reporting documented: -All reports of resident abuse shall be promptly reported to local and state agencies. Resident #7 was admitted to the facility on [DATE] with diagnoses that included: Encephalopathy, Acute Lymphoblastic Leukemia and Chronic Pain Syndrome. Review of Resident #7's medical record revealed the following: An Annual Minimum Data Set assessment dated [DATE] showed facility staff coded: clear speech, understands others and able to make self understood; a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition; no indicators of psychosis, rejection of care or behavioral symptoms. A physician's order dated 02/09/23 directed, CBC (complete blood count); Basic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to have documented evidence that an allegation of employee abuse was thoroughly investigated at the time when staff first had knowledge of the allegation. Resident #7. The findings included: Review of the policy Abuse Investigation and Reporting documented: -All reports of resident abuse shall be promptly and thoroughly investigated by facility management. Resident #7 was admitted to the facility on [DATE] with diagnoses that included: Encephalopathy, Acute Lymphoblastic Leukemia and Chronic Pain Syndrome. Review of Resident #7's medical record revealed the following: An Annual Minimum Data Set assessment dated [DATE] showed facility staff coded: clear speech, understands others and able to make self understood; a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition; no indicators of psychosis, rejection of care or behavioral symptoms. A physician's order dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) on nine (9) sampled residents, facility staff failed to accurately code Resident #5's resident's admission Minimum Data Set (MDS) assessment for a deep tissue injury on the sacrum. The findings included: Resident #5 was admitted to the facility on [DATE] with multiple diagnoses that included: Severe Protein- Calorie Malnutrition and Long Term use of Anticoagulants. A Skin and Wound Evaluation dated 11/03/22 at 7:51 AM documented that a pressure, deep tissue injury (DTI) on the sacrum was present on admission that measured 5.7 cm (centimeters) in length by 9.7 cm wide. An admission MDS assessment date 11/09/22 showed that in Section M (Skin Conditions), facility staff failed to code Resident #5's deep tissue injury as evidenced by the area that asked current number of deep tissue injury being left blank. A FRI, DC~11535, received by the State Agency on 01/20/23 documented that an allegation of neglect was received on 01/18/23 from Resident #5's daughter.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to revise one (1) resident's care plan to include use of an arm sling for immobilization for a right shoulder fracture. Resident #3. The findings included: Review of the facility policy Care Planning/Meeting - Interdisciplinary Team documented that the facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses that included: Hemiplegia and Hemiparesis and Contracture of Muscle, Left Upper Arm. Review of Resident #3's medical record revealed the following: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded: totally dependent with two persons physical assist for bed mobility, transfer and had functional impairment in range of motion on both sides for upper and lower extremities. A Situation Background Assessment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to ensure that a resident who was unable to carry out activities of daily living received the necessary care and services to maintain grooming and personal hygiene. Resident #6. The findings included: Review of the facility policy Activities of Daily Living (ADLs), Supporting documented that residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good grooming and personal hygiene (bathing, dressing grooming and oral care). Resident #6 was admitted to the facility on [DATE] with diagnoses that included: Urinary Incontinence, Cognitive Communication Disorder, and Muscle Wasting and Atrophy. Review of Resident #6's medical record revealed the following: A care plan focus area [Resident #6] has an ADL self-care performance deficit that was initiated on 03/07/22 had interventions that included: provide sponge bath when a full bath or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interview, for one (1) of nine sampled residents, facility staff failed to ensure one (1) resident received appropriate care and services to prevent potential complications (contamination and infection) of enteral feedings. Resident #3. The findings included: Review of the facility's policy Enteral Feedings - Safety Precautions documented: -The facility will remain current and follow accepted best practices enteral nutrition -On the formula label document initials, date and time formula was hung. According to the National Institute of Health (NIH): -Hanging time is another factor on which safety of enteral feeding depends on -Closed containers are discarded after 24 hours due to current manufacturer recommendations -Besides the feed, even the feeding delivery sets can be a source of contamination. Hence, they also need to be replaced every 24 hours. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7519612/ Resident #3 was admitted to the facility on [DATE] with multiple…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, facility staff failed to updated their COVID-19 policies and procedures to include contingency plans for staff who are not fully vaccinated. The resident census on the first day of survey was 110. The findings include: Review of the facility's line listing of staff who were vaccinated showed that six (6) staff had not received the vaccine and applied for an exemption with the State Agency. It was further noted that two (2) of the staff members worked in non-resident areas; and four (4) of the staff members performed direct resident care. During the face-to-face meeting with Employee #29 (Infection Control Preventionist) on 03/23/22 at approximately 4:45 PM, an Infection Control interview and review of the facility's infection control policies and procedures was done. It was noted that the policy did not address a contingency plan for staff who are not fully vaccinated due to a pending request for an exemption or that have been granted exemptions. Employee #29 stated that all of the employees had filed to be exempt with the State Agency and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to implement its Abuse Investigation and Reporting policy by not investigating the following incidents: (1) a resident who had an unwitnessed fall with injury resulting in the resident being transferred to the hospital for evaluation; (2) a resident who sustained a minor injury after a portable fan fell on the resident; (3) a resident who had a witnessed fall with a minor injury; (4) a resident who had an unwitnessed fall without injury; (5) a resident whose gastrostomy tube was dislodged; and (6) a residents whose midlines were dislodged. Residents' #30, #32, #79, #263, #105 and #207. The findings include: Review of the facility's policy titled, Abuse and Neglect- Clinical Protocol, dated 11/01/21, defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 53 sampled residents, facility staff failed to have an admissions policy in place; and failed to ensure residents and or their responsible party reviewed and signed an admission contract, informing them of the facility's approach to finances, residents' rights, care, treatment and services, and advance directives. Resident #95. The findings include: Facilty staff failed to ensure Resident #95 and or their responsible party reviewed and signed an admission contract. Resident #95 was admitted on [DATE] with diagnoses that included Chronic Respiratory Failure with Hypoxia or Hypercapnia, Cerebral Palsy, Pressure Ulcer Stage 4, Tracheostomy and Gastrostomy Review of the Resident's contract on 03/17/2022 dated showed that it was not dated and signed by the resident's responsible party. There is no evidence that Resident #95 or his responsible party was made aware of or provided notice regarding: Statement of Services and Charges, the Representatives' Rights…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews, and staff interviews, for six (6) of 53 sampled residents, the facility's staff failed to develop a care plan with goals and approaches to address: the use of a portable fan; monitoring a resident for signs and symptoms of Depression; and restorative nursing for a residents; Dementia care for a resident; the use of antibotics for a resident and to implement the interventions for a resident at risk for falls. (Residents' #32, #96, #79, #2, #262, and #263) The findings include: 1.The facility's staff failed to develop a care plan to address Resident #32's use of a portable fan. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses, including Respiratory Failure, Systemic Lupus, Ventilator Dependent, and Generalized Muscle Weakness. Review of a facility reported incident (FRI) received by the DC Department of Health on 06/28/21 documented that on 06/27/21 at 8;30 AM, the resident (Resident #32) sustained a small skin tear to the upper right braw [brow]…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record reviews and staff interviews, for four (4) of 53 sampled residents, facility staff failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan as evidenced by failure to: (1) provide activities of daily living (ADL) in a manner that prevented a Resident #29's midline (intravenous line) from being dislodged; (2) administer Vancomycin (antibiotic) liquid to Resident #55 by the incorrect route; (3) administer Midodrine (increases blood pressure) to Resident #81 in accordance with the physician's order; and (4) obtain orders to treat Resident #92's noted rash on the perineum and legs. The findings include: 1. Facility staff failed to provide activities of daily living in a manner that prevented Resident #29's midline from being dislodged. Resident #29 was admitted to facility on 12/27/21. The resident had a history of Multiple Sclerosis, Quadriplegia, and Sepsis. On 03/21/22 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, for two (2) of 53 sampled residents, the facility's staff failed to maintain Standards of Infection Control Practices when providing tracheostomy care for Resident #103 and when suctioning Resident #81. The findings include: 1.The facility's staff failed to maintain Infection Control Standards when providing tracheostomy care for Resident #103. Resident #103 was admitted to the facility on [DATE] with multiple diagnoses including Tracheostomy, Respiratory Failure, and Dependence on Respiratory Ventilator. On 03/15/22 at 10:11 AM, Employee #11 (Respiratory Therapist) was observed setting up a sterile field with equipment to provide trach care for Resident #103. After setting up the sterile field, Employee #11 performed hand hygiene and put on sterile gloves. The employee was noted contaminating her sterile gloves when she touched a pack of 4X4s lying on an uncleaned bedside table. The employee then touched the resident's inner cannula tracheostomy tube with her uncleaned…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for three (3) of 53 sampled residents, facility staff failed to ensure that there was documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization, the administration or the refusal of or medical contraindications to the vaccine(s). Residents' #6, #262 and #263. The findings include: 1. Resident #6 was readmitted to the facility on [DATE] with diagnoses that included Chronic Respiratory Failure, Anemia and Hypertension. Review of the Resident #6's Significant Change Minimum Data Set (MDS) dated [DATE] showed the resident was coded as not receiving the Influenza and Pneumococcal vaccinations and the stated reason was - offered and declined. Review of Resident #6's medical record (electronic and paper) lacked documented evidence that facility staff provided information/education to the resident or their representative regarding the benefits and risks of the influenza and pneumococcal immunization or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, facility staff failed to ensure that one (1) staff member was in compliance with receiving the COVID-19 vaccination series. The resident census on the first day of survey was 110. The findings include: According to the Centers for Disease (CDC) The number of doses needed depends on which vaccine you receive. To get the most protection: Two (2) Pfizer-BioNTech vaccine doses should be given 3 weeks (21 days) apart, two (2) Moderna vaccine doses should be given 1 month (28 days) apart and Johnson & Johnsons [NAME] COVID-19 vaccine requires only one dose. https://www.cdc.gov/coronavirus/2019-ncov/vaccines/faq.html#:~:text=The%20number%20of%20doses%20needed,than%20the%20recommended%20interval. According to the District of Columbia Department of Health (DC DOH), All licensees in the District of Columbia are required to be fully vaccinated against COVID-19. Licensees must have the single dose [NAME] COVID-19 vaccine, or at least one dose of either the Pfizer or Moderna…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility's staff failed to provide Advance Directive information to incapacitated resident or their representatives; and to offer a resident or their representative the opportunity to formulate an Advance Directive for three (3) of 53 sampled residents (Residents' #30, #96 and #26). The findings include: 1. Resident #30 was admitted to the facility on [DATE] with multiple diagnoses, including Respiratory Failure, Brain Stem Stroke Syndrome, and Atrial Fibrillation. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed that the Resident was coded for having memory problems with short-term and long-term memory and severely impaired cognitive skills for decision making. Review of the Resident #30's face sheet shows the resident had a representative (daughter). Review of the resident's medical record showed the resident was a Full Code. However, the record lacked documented evidence the Resident #30's representative was provided information about Advance…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff and resident's representative interview, the facility's staff failed to notify a resident's representative of a resident's change in status (self-decannulation), which resulted in the resident being transferred to the emergency room for re-insertion of a tracheostomy tube for one (1) of 53 sampled residents (Resident #102). The finding included: Review of a complaint received by the DC Department of Health on 02/28/21 documented, He [the complainant] received a call at 3:35 AM from [hospital's name] because his sister .trach [tracheostomy tube] came out or she pulled it out .he never received a call from the facility indicating his sister was being transferred. Resident #102 was admitted to the facility on [DATE] with multiple diagnoses, including Chronic Respiratory Failure, Tracheostomy, and Spastic Diplegic Cerebral Palsy. On 03/17/22 at approximately 9:30 AM, Resident #102 was observed lying in bed with a tracheostomy tube and trach collar at 28% FiO2[fraction of inspired…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, for one (1) of 53 sampled residents, facility staff failed to provide documented evidence that a baseline care plan was provided to a resident or his representative within 48 hours of readmission into the facility. Resident #63 The findings include: Resident #63 was readmitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Cerebrovascular Accident (CVA), Encounter For Attention To Gastrostomy, Encephalopathy and Urinary Tract Infection. Review of the Quarterly Minimum Data Set, dated [DATE], facility staff documented that Resident #63 had a Brief Interview Mental Status Summary Score (BIMS) of 00 indicating the resident, had severe cognitive impairment. In addition, facility staff documented the resident: was totally dependent, for bed mobility, transfers dressing, and eating; was always incontinent for bowel and bladder and had an indwelling urinary catheter, and the resident has a nasogastric or abdominal feeding tube percutaneous…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) of 53 sampled residents, facility staff failed to accurately record the location and status of a wound Resident #261's. The findings include: Resident #261 was admitted to the facility on [DATE] with diagnosis that included Epilepsy, Hypertension, Retention of Urine, Malignant Neoplasm of Prostate and Chronic Vascular Disorders of Intestine. Review of the clinical record showed the following: 08/25/21 [Situation Background Assessment Request (SBAR) Situation - Open Blister on the left buttocks (no measurements recorded) . Resident alert and responsive, during morning care the open blister was noted on his left buttock .Order given to clean with wound cleanser pat dry and apply xeroform daily. 08/26/21 [Skin and Wound Evaluation] Location: Sacrum; Describe: Pressure, Unstageable: Obscured full-thickness and tissue loss, slough and/or eschar; In house- acquired on 0825/2021; wound measurements: 4.1 cm (centimeter) x 4.0 cm x 0.2 cm; Granulation 6.50% would…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, for two (2) of 53 sampled residents, the facility's staff failed to (1)provide supervison during activities of daily living (ADL) care which resulted in Resident #29's midline (intravenous line) being dislodged and (2) ensure that a space heater was not used to heat Resident #1's room. The findings included: 1. Facility staff failed to provide activities of daily living in a manner that prevented Resident #29's midline from being dislodged. Resident #29 was admitted to facility on 12/27/21. The resident had a history of Multiple Sclerosis, Quadriplegia, and Sepsis. On 03/21/22 at approximately 2:15 PM, an observation showed Resident #29 lying in bed with a double lumen midline in the right upper extremity. The mid-line's transparent dressing was dry and intact. Further observation showed the midline insertion site had no drainage, redness, or swelling. The resident was wearing a hospital gown with snaps. And the resident's bilateral upper extremities were contracted. Review of Resident #29's medical record showed the following: 03/02/22 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for two (2) of 53 sampled residents, facility's staff failed to address an unusual weight for a resident; and failed to ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight. Residents' #30 and #63. The findings included: Review of the Nutritional Assessment policy dated 11/02/21documented that the dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident .as indicated by a change in conditions that places the resident at risk for impaired nutrition .The assessment will be conducted by the multidisciplinary team and shall at least include the following components .nursing[will assess]unusual weight .dietitian[will determine] whether the resident's current intake is adequate to meet his or her nutritional needs. Review of the Weight Assessment and Intervention policy dated 11/09/21 documented that the nursing staff will measure residents'…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for three (3) of 53 sampled residents, facility staff failed to ensure the residents with Midlines (A catheter that is inserted in a peripheral vein and ends near the upper arm use for intravenous therapy) were assess for complications at the insertion site during the therapy and post removal or dislodgement of the catheter. (Residents' #55, #93, and #63.) The findings include: 1.Failed to assess Resident #55's Midline insertion site post removal or dislodgement; and failed to document the discontinue of the residents Midline. Resident #55 was readmitted to the facility on [DATE] with diagnoses that included Diffuse Traumatic Brain Injury with Loss of Consciousness, Dysphagia, Anxiety Disorder, Anoxic Brain Damage, Hypertension, Clostridium Difficile (C-Diff), and Urinary Tract Infection (UTI). Review of the Quarterly MDS dated [DATE] showed Resident #55 was coded as follows: Section C (Cognitive Pattern) his Brief Interview for Mental Status (BIMS) the resident is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews for (1) one of 53 sampled residents, facility staff failed to provide respiratory care that is consistent with professional standards of practice for one resident who was receiving humidified oxygen. Resident #34. The findings include: Resident #34 was admitted to the facility on [DATE] with diagnoses including, Chronic Respiratory Failure , Unspecified, Dysphagia, Shortness of Breath, and Dependence on Supplemental Oxygen. Review of the Quarterly Minimum Data Set, dated [DATE], facility staff documented that Resident #34 had a Brief Interview Mental Status Summary Score (BIMS) of 10 indicating the resident, had mild cognitive impairment. In addition, facility staff documented: the resident: was totally dependent and required assistance from one person for all ADL(assisted daily living) care, and was always incontinent for bladder. Review of Resident #34's medical record revealed: 10/02/21 (Physician's Order): Change Nasal Cannula Tubing/Mask and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview for one (1) out of 53 sampled residents, facility staff failed to provide treatment, services, and develop a plan of care for Resident #2's diagnosis of dementia. Resident #2 The findings include: Resident #2 was admitted to the facility on [DATE], with multiple diagnoses that included: Unspecified Dementia with Behavioral Disturbance, Major Depressive Disorder, and Psychotic Disorder with Hallucinations due to Known Physiological Condition. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed that the facility staff coded the following: In section C (Cognitive Patterns): Brief Interview for Mental Status (BIMS) Summary Score 10 indicating moderately impaired cognition. In section I (Active Diagnoses): Neurological, Non-Alzheimer's Dementia Review of the medical record revealed that there was no documented evidence of a dementia care plan with goals that were achievable and interventions that were person-centered to address care needs of the resident. A…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and staff interviews, facility staff failed to ensure one (1) expired vial of influenza vaccine and one (1) vial of tuberculin Purified Protein Derivative, PPD injection, were discarded and not stored for use in two (2) of three (3) medication refrigerators observed. The findings include: According to the manufactures speciation's for the Influenza Vaccine stipulated, 16.2 Storage and Handling .Once the stopper of the mulit-dose vial has been pierced the vial must be discarded within 28 days. https://www.fda.gov/media/117022/download According to the manufactures speciation's for the Tuberculin Purified Protein Derivative, stipulated, Storage .A vial of Tubersol [Tuberculin Purified Protein Derivative] which has been entered and in use for 30 days should be discarded. https://www.fda.gov/media/74866/download 1.On [DATE] at 3:18 PM an observation of the 4th floor medication storage room refrigerator was conducted. Observed stored was a vial of Afluria 2021-2022 Quadrivalent (Influenza…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviw for two (2) of 53 sampled residents, facility staff failed to ensure Resident #78 received the appropriate treatment when he/she complained of pain during urination; and failed to obtain labs in accordance with the physician's order for Resident #81. The findings include: 1. Facility staff failed to ensure Resident #78 received the appropriate treatment when he/she complained of pain during urination. Resident #78 was admitted to the facility on [DATE] with diagnoses that included Neuralgia and Neuritis, Muscle weakness, anxiety disorder, and Lymphedema Review of the Quarterly MDS dated [DATE] showed the following: Section C (Cognitive Patterns), facility staff coded Resident #78 with a Brief Interview for Mental Status (BIMS) summary score of 13, indicating intact cognitive response. Section G (Functional Status), Resident #78 was coded for needing extensive supervision with two person assistance for bed mobility, transfers, toilet use, personal hygiene. Section H…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.