Ingleside At Rock Creek

Based on observations and staff interview, facility staff failed to prepare, and distribute foods under sanitary condition, as evidenced by one (1) of one (1) open, and expired eyewash solution in the east-wing kitchen, one (1) of one (1) dishwashing machine in the east-wing kitchen that was leaking, one (1) of one (1) empty paper towel dispenser in the east-wing kitchen, one (1) of one (1) broken paper towel dispenser in the west-wing kitchen, one (1) of one (1) expired eyewash solution in the west-wing kitchen, no handwashing soap for one (1) of one (1) handwashing sink in the west-wing kitchen, dust and/or foreign substance accumulation in one (1) of one (1) walk-in refrigerator, and four (4) of four (4) ready-to-eat food packages that were inappropriately stored in the walk-in refrigerator. The findings included: During observations in dietary services on February 26, 2025, at approximately 9:00 AM, the following was observed: 1. A bottle of eyewash solution located in the east-wing kitchen was open and expired as of 09/2024. 2. One (1) of one (1) dishwashing machine in 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.

Based on a review of the facility's records and a staff interview, the facility failed to comply with the State Regulation (22B DCMR section 3211.5) for daily staffing ratios, as evidenced by not providing the minimum daily average of at least six tenths (0.6) hours of resident care per resident by a Registered Nurse for seven (7) of 43 sampled days. The findings included: A review of the facility's daily staffing sheets revealed the following: On 03/30/24 the facility's resident census was 27. In addition, residents received 0.5 hours of direct nursing care being provided by a Registered Nurse. On 03/31/24 the facility's resident census was 27. In addition, residents received 0.2 hours of direct nursing care being provided by a Registered Nurse. On 04/30/24 the facility's resident census was 27. In addition, residents received 0.2 hours of direct nursing care being provided by a Registered Nurse. On 12/25/24 the facility's resident census was 29. In addition, residents received 0.5 hours of direct nursing care being provided by a Registered Nurse. On 12/31/24 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.

Based on observations and interview, facility staff failed to maintain essential kitchen equipment in good working condition as evidenced by one (1) of one (1) dishwashing machine in the east-wing kitchen that squirted a water solution on both sides of the machine during the wash and rinse cycles. The findings included: During a walkthrough of the east wing kitchen at approximately 9:00 AM, on February 26, 2025, one (1) of one (1) dishwashing machine repeatedly spurted a water solution on both sides of the machine during the wash and rinse cycles. During a face-to-face interview on March 3, 2025, at approximately 10:00 AM, Employee #17 acknowledged the findings.

Based on observations and staff interview, facility staff failed to maintain an effective pest control program as evidenced by flying insects that were observed around one (1) of one (1) handwashing sink in the east-wing kitchen. The findings included: During observation on 2/26/2025 at approximately 9:00 am, flying insects were observed around one (1) of one (1) handwashing sink in the east-wing kitchen of the facility. During a face-to-face interview on 2/26/2025 at approximately 9:00 AM, Employee #17 stated that the facility receives pest extermination services from a professional company regularly and as needed. He added he will call the exterminator as soon as possible to address the problem. During a face-to-face interview on March 3, 2025, at approximately 10:00 AM, Employee #17 acknowledged the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for five (5) of 22 sampled residents, the facility staff failed to ensure that residents had collaborative hospice care plans between the hospice agency and the facility that included a description of the care, services, and frequency of visits to be provided by the contracted hospice provider. (Residents' #13, #17, #16, #21, #27) The findings included: 1. Resident #13 was admitted to the facility on [DATE] with diagnoses that included: Dementia, Atrial Fibrillation, Hypothyroidism, and Anemia. A review of a [Physician's order] dated 06/09/21 documented, admitted to [Hospice provider name] for dx [diagnoses] of Cerebral Atherosclerosis. A review of the facility care plan showed [Resident #13 name] is on [hospice provider] care. Last revised 8/20/23. Goal: receives hospice treatment, she will be kept comfortable for quality of life. Interventions: Continue to receive services from [Hospice agency name] as it relates to comfort care and ensuring all medical equipment…

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 three (3) sampled residents, facility staff failed to notify Medicaid residents when the amount in their account reached $200 of the SSI (supplemental security income) resource limit for both resident's accounting of funds. Residents' #6 and #7. The findings included: According to District of Columbia Department of Health Care Finance, .You may be eligible for Medicaid coverage of Long Term Care (LTC) services, if you: .Have resources up to $4,000 (asset limits) for one person . https://dhcf.dc.gov/service/long-term-care-ltc 1. Resident #6 was admitted to the facility on [DATE]. A review of the facility Trial Balance record dated 11/03/23, showed a current balance of $4,296.15 for Resident #6. 2. Resident #7 was admitted to the facility on [DATE]. A review of the facility Trial Balance record dated 11/03/23, showed a current balance of $4,497.67 for Resident #7. A face-to-face interview was conducted on 12/06/23 at 1:00PM with Employee#2, [Director of…

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, the facility staff failed to provide adequate surety bond coverage to assure the security of all residents' personal funds deposited with the facility. The Resident census on the first day of the survey was 30. The findings included: A review of the Surety Bond dated the effective date of 05/06/23, and expiration date of 05/06/24, shall be continued until canceled by the Surety Provider .or the Oblige (the Facility) in the amount of $100,000.00. A review of the Resident Funds Trust Account RMFS (Resident Fund Management Service) statements for 08/01/23, to 10/03/23, revealed the following bank account balance: Totaled for statements dated: August 2023 = $123,976.18 September 2023 = $124,237.60 October 2023 = $124,359.08 There was no evidence that the facility staff maintained a surety bond to cover the amount of funds in the resident funds account for August 2023 - October 2023. During a face-to-face interview on 12/07/23, at approximately 12:20 PM with Employee #2. She acknowledged the findings.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, resident representative, and staff interviews, for one (1) of 22 sampled residents, the facility staff failed to show documented evidence of notifying Resident #2's responsible party of a change in the resident's medical status on 12/01/22 and of the residents unwitnessed fall that occurred on 01/29/23. The findings included: A review of the facility policy titled Change in a Resident's Condition or Status with a revision date of 02/2021, instructs staff to do the following: .Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: the resident is involved in any accident or incident that results in an injury including injuries of an unknown source; .Except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status . Resident #2 was admitted to the facility on [DATE], with multiple diagnoses that included Dementia, Primary Generalized…

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 22 sampled residents, the facility staff failed to implement its written policies and procedures for allegations of potential abuse neglect as evidenced by the facility staff failing to show documented evidence of conducting a thorough investigation into a residents fall. (Residents #135) The findings included: A review of the facility's policy titled Accident and Incident Report with a revision date of 10/2019, documented All accidents or incidents involving residents will be documented on the Accident/ Incident Report Form .The Nurse Supervisor or Charge Nurse shall initiate and complete an Accident/incident form at the time of the incident. The following data will be documented on the incident form .brief description of incident -facts only, no assumptions should be made. Document only what is observed A review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating with a revision date of 4/2023,…

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 22 sampled residents, the facility staff failed to show documented evidence of conducting a thorough investigation into a residents fall. (Resident #135) The findings included: A review of the facility's policy titled Accident and Incident Report with a revision date of 10/2019, documented All accidents or incidents involving residents will be documented on the Accident/ Incident Report Form .The Nurse Supervisor or Charge Nurse shall initiate and complete an Accident/incident form at the time of the incident. The following data will be documented on the incident form .brief description of incident -facts only, no assumptions should be made. Document only what is observed A review of a facility policy titled Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigating with a revision date of 4/2023, documented .If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, 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 (1) of 22 sampled residents, the facility staff failed to provide written notice of the bed hold policy to include the number of bed hold days to the resident or their responsible party upon transfer to the emergency room. (Resident #135) The findings Included: Resident #135 was admitted to the facility on [DATE], with multiple diagnoses that included Unspecified Fracture of Right Femur, Subsequent Encounter for Closed Fracture with Routine Healing, Repeated Falls, Syncope and Collapse. A review of a Facility Reported Incident (FRI) DC#00011029, submitted by the facility to the State Agency on 10/13/22, documented .At about 9.10 pm, resident was observed lying on the floor in her room (on her Back side) with face up. Head to toe assessment done. No injury or skin issues noted. Resident complain of pain and medicated with PRN (as needed) pain medication . A review of Resident #135's medical record revealed the following: [Health Status Note] 10/12/22 at 10:37…

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 22 sampled residents facility staff failed to accurately code a resident for hospice on a quarterly Minimum Data Set (MDS) assessment. Resident #21. The findings included: Resident #21 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia, Non-traumatic Brain Disorder, Bipolar Disorder, Anxiety, Weakness, Heart Disease, Fracture of Left Femur, and Unspecified Fall of Subsequent Encounter. A review of Resident #21's medical record revealed the following: An informed consent form dated 06/24/22 and signed by the Resident's representative for the resident to start hospice services. A physician's order dated 06/25/22 at 4:07 PM that documented: Admit to [Name of Hospice] for hospice services. Diagnosis: Cerebral Arthrosclerosis. Please call [Name of Hospice] at [Hospice Phone Number]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the Resident had a Brief Interview for Mental Status Summary score of 03…

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 22 sampled residents facility staff failed to update and revise the care plan with resident-centered goals for one (1) resident's use of bilateral hand palm protecters. (Residents' #1). The findings included: Resident #1 was admitted to the facility on [DATE], with multiple diagnoses that included: Osteoarthritis, Right-Hand Contracture, and Left-Hand Contracture. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the resident as having a Brief Interview for Mental Status Summary score of 00 indicating the resident had severely impaired cognition, required extensive assistance for all ADL (assisted daily living) care, and had upper extremity impairment on both sides. A review of a [Physician's Order] dated 11/28/23 at 3:00 PM documented: Patient to wear left and right palm protectors for 4-5 hours a day. On 11/28/23 at 3:13 PM Resident #1 was observed by the Surveyor awake and lying-in bed with…

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 two (2) of 22 sampled residents, facility staff failed to provide adequate supervision consistent with a resident's needs, goals, and care plan to reduce the risk of an accident, subsequently, a resident had an unwitnessed fall; facility staff failed to ensure a resident who was identified as having a high fall risk on admission received adequate supervision to prevent injury of unknown origin. Subsequently, the resident was observed with discoloration on her right eyelid and a raised area around her eyebrow; and the facility failed to provide an environment free from accident hazards as evidenced by three (3) of 51 oxygen tanks that were unsafely stored in the oxygen storage room on the [NAME] side of the facility. (Residents' #11 and #22.) The findings included: 1.Facility staff failed to provide adequate supervision consistent with Resident #11's needs, goals, and care plan to reduce the risk of an accident, subsequently, the resident had an…

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 22 sampled residents, the facility staff failed to show documented evidence of reconciling Resident #27's prescribed controlled substance medication with the Pharmacy delivery staff on multiple occasions; and failed to record when controlled substance medication (Fentanyl patches) were received on the narcotic medication reconciliation log for the resident. The findings included: A review of the facility's policy titled Controlled Substances with a revision date of 5/2023, instructs staff to do the following: .Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record .an individual resident controlled substance record is made for each resident who will be receiving a controlled substance .the record contains: quantity received; date and time received signature of…

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 22 sampled residents, facility staff failed to acknowledge and/or respond to the pharmacist medication regimen review recommendation. Residents' #6 and #25. The findings included: 1. Facility staff failed to acknowledge and/or respond to the pharmacist's medication regimen review recommendations for Resident #6. Resident #6 was admitted to the facility on [DATE] with diagnoses that included Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Hypertension, Diabetes Mellitus, Anxiety Disorder, and Major Depressive Disorder. According to the Medication Administration Record Resident #6 nurse staff signed that the resident received the following medications: Vibryd 20mg [milligram], Tamsulosin HCL [Hydrochloride] 0.4mg capsule, Pradaxa 150mg capsule, Bevespi Aerosphere inhaler 2 puffs, Metoprolol Tarte 25mg, Furosemide 20mg, and Novolog 100unit/ml [milliliters] per sliding scale. On the following dates 2/18/23, 5/16/23, and 11/21/23 the monthly Health…

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, staff and resident representative interviews for one (1) of 22 sampled residents, the facility staff failed to ensure that Resident #27 was free from a significant medication error as evidenced by the resident being observed with three (3) Fentanyl patches on at once by the facility's staff and the residents relative. The findings included: A review of the facility's policy titled Administration Procedures for All Medications with an effective date of 8/2018, instructs staff to do the following: .Prior to removing the medication package/container from the cart/drawer. Check MAR (medication administration record)/TAR (treatment administration record) for order . A review of the facility's policy titled Medication Administration-General Guidelines with an effective date of 8/2018, documents the following: .Medications are administered in accordance with written orders of the prescriber. Resident #27 was admitted to the facility on [DATE], with multiple diagnoses that included Fracture of…

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 store and distribute food under sanitary condition as evidenced by expired food items such as 12 of 14, V8 vegetable drinks that were in the kitchen on the East and [NAME] side of the facility. The findings included: During a walkthrough of dietary services on November 28, 2023, at approximately 12:00 PM, the following observations were made: 1. Six (6) of six (6) 5.5 fluid ounces of V8 vegetable drinks stored in the kitchen on the East side of the facility were expired as of July 17, 2023. 2. Six (6) of eight (8) 5.5 fluid ounces of V8 vegetable drinks stored in the kitchen on the [NAME] side of the facility were expired as of October 26, 2023. Employee #6 acknowledged the findings during a face-to-face interview on November 28, 2023, at approximately 12:15 PM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews for one (1) of 22 sampled residents, facility staff failed to show documented evidence that a skin assessment was completed on admission, documented as ordered by the physician and weekly per the facility policy that accurately reflected a resident's change in skin condition. Resident #18. The findings included: Resident #18 was admitted to facility on 02/23/22 with multiple diagnoses that included: Dementia, Muscle Weakness, Difficulty Walking, Multiple Falls, Hypertension, Kidney Disease, Thyroid Disease and Anemia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '12,' indicating the resident had moderately impaired cognition; and coded the resident's functional status as 2-person physical assistance with toilet use and 1-person physical assistance with bed mobility, transfers, locomotion on/off unit, dressing, eating and personal hygiene. 1A) Facility…

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 provide a safe environment to residents and staff, as evidenced by three (3) of 51 oxygen tanks that were unsafely stored in the oxygen storage room on the [NAME] side of the facility. The findings include: During an environmental walkthrough on the [NAME] side of the facility on December 1, 2023, at approximately 8:45 AM, three (3) of 51 oxygen tanks were loosely stored upright, on the floor of the oxygen storage room, and presented an unsafe environment. Employee #3 who was present at the time of observation, acknowledged the above findings during a face-to-face interview on December 1, 2023, at approximately 9:00 AM.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews for six (6) of 21 sampled residents, facility staff failed to provide documented evidence that they informed and provided written information on the right to formulate an advanced directive to residents or their representatives. Residents' #16, #18, #20, #24, #25 and #131. The findings included: 1. Resident #16 was admitted to the facility on [DATE] with diagnoses including Fracture of Unspecified Part of Neck of Left Femur, Weakness, Unspecified Glaucoma, Dependence on Supplemental Oxygen, and Non-Alzheimer's Dementia. Review of an admission Minimum Data Set (MDS) dated [DATE], revealed that facility staff coded Resident #16 with a Brief Interview for Mental Status (BIMS) summary score of 00, indicating that the resident had severe cognitive impairment. Review of Resident #16's medical record revealed the following: A face sheet which documented that the resident had a representative. 05/25/22 [Physician's order] documented, Full Code. There was no documented…

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 review of facility documentation and staff interview, it was determined that the facility failed to ensure that one (1) of three (3) Beneficiary Notices contained sufficient information to ensure that the resident and/or responsible party had sufficient time to appeal the facility's decision to terminate Medicare services (Resident #133). The findings included: Resident #133 was admitted to the facility on [DATE], with diagnoses included the following: Discitis of the Cervical Region, Spinal Stenosis, Unspecified Injury of the Neck, and Need for Assistance with Personal Care. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed that facility staff coded Resident #133 with a Brief Interview for Mental Status (BIMS) summary score of 14, indicating that the resident had intact cognition. Review of the instruction on the Notice of Medicare Non-Coverage (NOMNC) stipulates, How to ask for an Immediate Appeal .Your request for an immediate appeal should be made as soon as possible, but no later…

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 21 sampled residents, facility staff failed to provide written notification to the resident or resident representative of the bed hold policy and the number of bed hold days remaining following residents transfer to the hospital on [DATE]. Resident #132 The findings included: Review of the facility's policy titled, Bed-Holds and Returns date revised 04/19, revealed .Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy . Resident #132 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Unsteadiness on feet, Muscle Weakness, and Chronic Kidney Disease Stage 3 Unspecified. Review of a admission Minimum Data Set (MDS) dated [DATE] revealed that facility staff coded Resident #132 with a Brief Interview for Mental Status (BIMS) summary score of 14 indicating that he was cognitively intact. Review of an intake for a Facility Reported…

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 21 sampled residents, facility staff failed to implement Resident #25's person-centered comprehensive care for contractures. The findings included . Resident #25 was admitted to the facility on [DATE] with multiple diagnoses including Generalized Muscle Weakness and Contracture of Right Hand and Contracture of Left. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed that facility staff coded Resident #25 with a Brief Interview for Mental Status (BIMS) summary score of 00, indicating that the resident had severe cognitive impairment. Under Section G (Functional Mobility), facility staff coded the resident as requiring extensive assistance for bed mobility, dressing, eating, and personal hygiene. Facility staff coded the resident as being totally dependent on staff for transfers, and toilet use. Facility staff coded that the resident had limited range of motion due to impairment on both sides to the upper and lower extremities.…

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 ensure that the nurse's care and services for verification of shift count for narcotics drugs met the professional standard of practice. The findings included: According to All Care Pharmacy .All controlled substances . must be counted at each shift change. Both the oncoming and outgoing nurse should look at the card and the narcotic book to ensure accuracy . www.allcarepharmacy.com/facilityresources/assets/documents/Controlled A review of the facility Control Drugs Verification Count /Shift Count Sheet for Narcotics book on August 24, 2022, showed that the space allotted for (1) correct drug count -yes/no, (2) Balance verified by a nurse coming on duty (one signature only), (3) Balance verified by a nurse going off duty (one signature only) was being signed by one nurse in both space or is being left blank. This indicated, That professional standard of practice were not being met. During a face-to-face interview conducted with Employee #10 [East medication nurse] on 08/22/22 at 11:12 AM and Employee #6 [West…

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 21 sampled residents, facility staff failed to develop and complete a discharge plan for Resident #31 that was planning to return to the community. The findings included: Resident #31 was admitted to the facility on [DATE], with multiple diagnoses that included the following: Presence of Left Artificial Knee Joint, Syncope and Collapse and Pain in Unspecified Joint. Review of the 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 15 was coded indicating intact cognition. In section Q (Participation in Assessment and Goal Setting) Expects to be discharged to the community Review of the social services progress notes documented the following: 05/31/22 at 12:47 PM . (Resident #31's) discharge care plan meeting will be held on 6-1-22 at 12PM, as she will be transferring back to AL (Assisted Living) with her husband . 06/01/22 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 observations, record review, and staff interview, for one (1) of 21 sampled residents, facility staff failed to ensure that a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion. Resident #25. The findings included: Resident #25 was admitted to the facility on [DATE] with multiple diagnoses including Generalized Muscle Weakness and Contracture of Right Hand and Contracture of Left. Review of a Quarterly Minimum Data Set (MDS) dated [DATE] revealed that facility staff coded Resident #25 with a Brief Interview for Mental Status (BIMS) summary score of 00, indicating that the resident had severe cognitive impairment. Under Section G (Functional Mobility), facility staff coded the resident as requiring extensive assistance for bed mobility, dressing, eating, and personal hygiene. Facility staff coded the resident as being totally dependent on staff for transfers, and toilet use. Facility staff coded that the resident had limited…

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 interviews for two (2) of two (2) nursing units, the facility staff failed to ensure that the system used for an acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed. The findings included . 1. A review of the Shift count Narcotic records on Unit East was completed on August 24, 2022, at approximately 9:10 AM, and it showed the following activity in the Narcotic reconciliation record for the following dates: 4/11/2022 3-11 shift same nurse signed coming on and going off duty 4/15/2022 3-11 shift nurses coming on duty [blank] and 11-7 going off duty [blank] 4/26/2022 3-11 shift same nurse signed coming on and going off duty 5/8/2022 11-7 shift same nurse signed coming on and going off duty 5/22/2022 11-7 shift same nurse signed coming on and going off duty 6/20/2022 11-7 shift same nurse signed coming on and going off duty 7/12/2022 11-7 shift same nurse signed coming on and going off duty 7/30/2022 11-7 shift same nurse signed coming on and going off duty 8/13/2022…

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 observation and staff interview, facility staff failed to store and prepare foods in accordance with professional standards of practice for food services safety as evidenced by food items such as one (1) of one (1) one-gallon plastic bag with cubed pieces of ham, one (1) of one (1) container of cooked chicken wings, one (1) of one (1) one-gallon container of slaw dressing, and one (1) of one (1) one-gallon container of sweet pickle relish, that were not labeled or dated, pieces of flounder fish that were improperly being thawed, and boxes of ice cream and muffins that were inappropriately stored in one (1) of one (1) walk-in freezer. The findings included: During a walkthrough of the facility's kitchen on August 22, 2022, at approximately 10:00 AM, the following observations were made: 1. Food items in the walk-in refrigerator such as one (1) of one (1) one-gallon plastic bag with cubed pieces of ham, one (1) of one (1) container of cooked chicken wings, one (1) of one (1) one-gallon container of slaw dressing, and one (1) of one (1) one-gallon container of sweet pickle…

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 21 sampled residents, facility staff failed to ensure that Resident #131's medical record did not contain inaccurate information as evidenced by staff documenting resident did not have any falls in the past 3 months on multiple falls assessment despite the resident having a documented history of falls in the medical record. Resident #131 The findings included: Resident #131 was admitted to the facility on [DATE] with multiple diagnoses that include the following: Fracture of Unspecified Part of Neck of Right Femur, Unspecified Dementia Without Behavioral Disturbance, Subsequent Encounter and Methicillin Resistant Staphylococcus Aureus Infection . Review of a admission Minimum Data Set (MDS) dated [DATE] revealed that facility staff coded Resident #131 with a Brief Interview for Mental Status (BIMS) summary score of 09, indicating that the resident's cognition is moderately impaired. Review of resident's hospital discharge documents in the 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 observation, record review, and staff interview for one (1) of 21 sampled residents, facility staff failed to wear the required PPE (Personal Protective Equipment) when entering a resident's room and providing care for a resident that was on contact precautions due to MRSA (Methicillin-Resistant Staphylococcus Aureus). Resident #131 The findings included: Review of the facility's policy titled Infection Prevention and Control Program date revised 12/19, revealed the following: .Prevention of infection a. important facets of infection prevention include: (2) instituting measures to avoid complications or dissemination .educating staff and ensuring that they adhere to proper techniques and procedures; .(4) communicating the importance of standard precautions and cough etiquette to visitors and family members; .(7) Implementing appropriate isolation precautions when necessary; and (8) following established general and disease -specific guidelines such as those if the Centers for Disease Control (CDC) .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.