Washington Ctr For Aging Svcs

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to treat a resident with respect, dignity, and care, as evidenced by administering advanced life support measures to a resident who was not a Full Code. Resident #498. The findings included: Resident #498 was admitted to the facility on [DATE] with multiple diagnoses that included: Malignant Neoplasm of Breast, Respiratory Failure, Congestive Heart Failure, and Chronic Kidney Disease. A review of Resident #498's medical record revealed: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '13,' indicating the resident was cognitively intact; Functional Abilities an Goals coded as '02-Substantial/maximal assistance' with Sit to Stand position, Lower body dressing and Putting on/taking off footwear; '03-Partial/moderate assistance with Toileting hygiene, Shower/bathe self, Personal hygiene and Upper…

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 one (1) of 59 sampled residents, facility staff failed to ensure that a resident was free from physical restraint not required to treat the resident's medical symptoms, as evidenced by a siderail up at the foot of the resident's bed. Resident #105. The findings included: Resident #105 was admitted to the facility on [DATE] with multiple diagnoses that included: Blindness Both Eyes, Psychotic Disorder with Delusions, Hallucinations, Morbid Obesity and Muscle Weakness. A review of Resident #105's medical record revealed: A review of the facility's policy titled 'Restraint Usage 00 - 008' with a review and revised date of June 7, 2024, documented, Definition and Philosophy of Use: The RAI (Resident Assessment Instrument) User's Manual defined restraint as Any manual method of physical or mechanical device, material or equipment attached or adjacent to resident's body that the individual cannot remove easily, which restricts freedom or normal access to…

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 59 sampled residents, the facility staff failed to implement its policies and procedures for reporting and conducting investigations into potential allegations of neglect and or abuse. Resident #128. The findings included: A review of the facility's policy titled Incident and Accident dated revised on 01/03/24 documented the following: When actual incident occurs: Complete head to toe nursing assessment must be completed by the licensed nurse for both witnessed and unwitnessed incidents. Perform neurological assessments for all if appropriate Incident will be reviewed by the clinical team. Notification of physician and responsible party. Incident report must be sent to Department of Health (DOH) for all incidences. Investigation using the incident and accident form. Witness statement if appropriate. A review of the facility's policy titled Prohibition of Abuse that was undated directed Staff will complete an incident /accident form for any unusual…

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 59 sampled residents, the facility staff failed to show documented evidence that the facility reported the results of a follow up investigation to the State Agency within 5 working days of incidents in which Resident #128 was found unresponsive on 11/14/23, 3/5/24 and found with an injury of unknown origin and change in behavior on 4/10/24. Resident #128. The findings included: A review of the facility's policy titled Prohibition of Abuse that was undated directed, Staff will complete an incident /accident form for any unusual occurrences and submit it to the director of nursing or designee All alleged violations, substantiated incidents; corrective actions depending on the results of the investigation are reported verbally within 8-72 hours and in writing within 5 working days to the State Agency A review of a Facility Reported Incident (FRI) DC~00012281, submitted to the State Agency on 09/08/23 documented the following: Around 9:25 PM today 9/7/2023,…

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 three (3) of 59 sampled residents, facility staff failed to show documented evidence that thorough investigations were conducted for: 1) two incidents in which Resident #128 was found unresponsive on 11/14/23 and 3/5/24, and 2) one incident in which Resident #159 sustained an injury of unknown origin. The findings included: 1.A review of the facility's policy titled Incident and Accident dated revised on 01/03/24 documented the following: When actual incident occurs: Complete head to toe nursing assessment must be completed by the licensed nurse for both witnessed and unwitnessed incidents. Perform neurological assessments for all if appropriate Incident will be reviewed by the clinical team. Notification of physician and responsible party. Incident report must be sent to Department of Health (DOH) for all incidences. Investigation using the incident and accident form. Witness statement if appropriate. A review of the facility's policy titled Prohibition of Abuse…

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 59 sampled residents the facility staff failed to provide documented evidence of providing notification to the resident or resident guardian of the reason for the residents transfer to the hospital emergency room. Residents' #32 and # 445. The findings included: 1. The facility staff failed to provide documented evidence of providing notification to Resident #32 and thier representative of the reason for the residents transfer to the hospital. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Alzheimer's Disease, Adult Failure to Thrive, Chronic Kidney Disease and Abnormal Weight Loss. A review of Complaint #DC00012878 was submitted to the State Agency on 02/27/24 documented the following: Voicemail received on 2/27/24: My name is (Resident Representative). ( .) I wish to lodge a complaint against . (Facility Name) are located at (Facility Address). I have a I am legal Guardian of award (sp),…

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 59 sampled residents, the facility staff failed to provide documented evidence of forming a baseline care plan upon the residents readmissions to the facility. Residents #32 and #445. The findings included: 1. The facility staff failed to provide documented evidence of forming a baseline care plan upon the Resident #32's readmission to the facility on [DATE] and providing a copy of the baseline care plan summary to the resident and resident representative. Resident #32 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Alzheimer's Disease, Adult Failure to Thrive, Chronic Kidney Disease and Abnormal Weight Loss. A review of Complaint #DC00012878 was submitted to the State Agency on 02/27/24 documented the following: Voicemail received on 2/27/24: My name is (Resident Representative). ( .) I wish to lodge a complaint against started (Facility Name) are located at (Facility Address). I have a I am legal Guardian 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 one (1) of 59 sampled residents, the facility staff failed to update the comprehensive care plan with goals and approaches that address the resident's post-dialysis care for a right upper arm AVF [Arteriovenous fistula] access site and respiratory care /treatment. (Resident #249). The findings included: Resident #249 was admitted to the facility on [DATE] with multiple diagnoses including Diabetes Mellitus, End-stage Renal Disease with dependence on Renal dialysis, Anemia, Hypertension, Hyperlipidemia, and Congestive Heart Failure. A. Facility staff failed to update the comprehensive care plan with goals and approaches that address Resident #249's post-dialysis care for a right upper arm AVF access site. Review of Resident #249 physician order date 04/13/2024 18:00 [6:00 pm] directed Remove pressure dressing from left AVG [AVF] 24 hours after dialysis observe for bleeding and document result in nursing notes once a day on Tuesday, Thursday, and Saturday 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Resident #105. Resident #105 was admitted to the facility on [DATE] with multiple diagnoses that included: Blindness Both Eyes, Psychotic Disorder with Delusions, Hallucinations, Morbid Obesity and Muscle Weakness. A review of Resident #105's medical record revealed: A Care Plan Problem dated 05/17/2023 documented, Category: ADLs (Activities of Daily Living) Functional Status/Rehabilitation Potential, Self care deficit and Evaluation Notes: 11/16/2023, Staff will continue to provide total ADL care. A Physician Note dated 05/10/2024 at 11:44 pm documented, debilitated, bedbound and dependent with all ADLs. A Discharge Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded a Brief Interview for Mental Status (BIMS) summary…

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 resident and staff interviews for two (2) of 59 sampled residents, facility staff failed to provide care and services for a resident newly diagnosed with cancer, as evidenced by failing to ensure that the resident had scheduled follow-up oncology appointments and had transportation to the appointments. Resident #76 The findings included: Resident #76 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Fracture of the left Femur, Type 2 Diabetes Mellitus, Nonspecific Finding of Lung Field, and Schizoaffective Disorder. A review of Resident #76 's medical record revealed: A review of a Quarterly Minimum Data Set (MDS) assessment dated [DATE] that showed Resident #76 had a Brief Interview for Mental Status (BIMS) summary score of 11 indicating moderately impaired cognition, required setup or clean assistance by staff for eating, and was dependent on staff for assistance with all other activities of daily living (toileting, personal hygiene, bathing 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 resident and staff interviews for two (2) of 59 sampled residents, facility staff failed to ensure that residents received the proper treatment and assistive devices to maintain vision and hearing abilities as evidenced by failure to schedule an ophthalmology consult appointment for a resident with Diabetes and Glaucoma, and failure to schedule an initial audiology consult appointment for a resident with impaired hearing. Residents #112 and #162. The findings included: 1)Resident #112 was admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus with Hyperglycemia, Partial Amputation of Left Foot, and Chronic Angle -Closure Glaucoma, Right Eye, Stage Unspecified. A review of the resident's medical record revealed: A review of a physician's order dated 02/03/24 directed: Consult: Ophthalmology consult eval(uation) and treat as needed. A review of a physician's order dated 04/02/24 directed: Azopt Ophthalmic Suspension 1% (Brinzolamide) [eyedrops] Instill…

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 for one (1) of 59 sampled residents, facility staff failed to ensure that the resident received respiratory care, consistent with professional standards of practice and the physicians orders as evidenced by the facility's staff's failure to follow the physicians order to place a date and initials on the residents oxygen tubing once each week and the staff failed to display an oxygen in use and no smoking sign in the residents room. Resident #21 The findings included: A review of the facility's policy titled Oxygen Administration-Nasal Cannula that was undated documented the following: Oxygen is administered according to physicians orders and in observance of all safety precautions. Equipment Nasal cannula, no smoking signs, portable oxygen tank, connector. Procedure: Place water in humidifier to indicated level and post the no smoking sign on the door and in the residents room-oxygen is highly combustible .Chart the time, procedure, rate of flow 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.

Based on observations and staff interview, facility staff failed to distribute foods under sanitary condition, as evidenced by two (2) of two (2) defective temperature gauges from one (1) of one (1) food warmer, that failed to register the upper and lower internal temperatures of the food warmer. The findings include: During observations in dietary services on June 25, 2024, at approximately 10:30 AM, two (2) of two (2) temperatures gauges from one (1) of one (1) food warmer were broken and did not display the correct upper and lower internal temperatures of the food warmer. During a face-to-face interview on July 1, 2024, at approximately 2:00 PM, Employee #12 acknowledged the findings. CROSS REFERENCE:DCMR TITLE 22B Sec 3219.1

Based on record review and staff interview, facility failed to correct and monitor deficiencies identified on the previous survey that involved baseline care plans and implementing care plan interventions. The census on the first day of the survey was 194. The findings included: A review of the facility's previous survey from dates 06/24/24 to 07/16/24 showed that the facility was cited for the following deficiencies: F655 - Baseline care plan F656 - Develop/Implement Comprehensive Care Plan The aforementioned deficiencies were cited again during the Revisit Survey that was conducted from 09/17/24 to 09/18/24. Review of the Plan of Correction with a compliance date of 08/31/24, revealed that facility staff failed to continuously monitor their deficient practices from the prior survey and failed to implement the corrective actions as indicated below: Under F655 - Monitoring Corrective Actions - Monthly audit tool on readmission was developed to track all re-admission baseline care plan. Any deficiency will be corrected immediately. Under F656 - Monitoring Corrective Actions 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.

Based on observations on June 25, 2024, at approximately 2:30 PM, and staff interview, it was determined that facility staff failed to maintain essential equipment in good working condition, as evidenced by three (3) of seven (7) hopper sinks, that failed to operate as intended. The findings included: Three (3) of seven (7) hopper sinks, each located in the soiled utility room on each unit, did not flush when tested. Employee #25 acknowledged the findings during a face-to-face interview on July 1, 2024, at approximately 4:00 PM. Cross Reference- 22B DCMR Sec.3258.3

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and staff interviews for one (1) of 59 sampled residents, facility staff failed to provide a safe, functional, sanitary, and comfortable environment for a resident who is totally dependent on staff, as evidenced by the resident's room filled with clutter. Resident #105. The findings included: Resident #105 was admitted to the facility on [DATE] with multiple diagnoses that included: Blindness Both Eyes, Psychotic Disorder with Delusions, Hallucinations, Morbid Obesity and Muscle Weakness. A review of Resident #105's medical record revealed: A Physician Note dated 05/14/2024 at 11:35 pm documented, The resident at baseline is debilitated, bedbound and dependent with all ADLs (Activities of Daily Living). A Discharge Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '11' indicating the resident was moderately impaired; Functional Abilities and Goals coded '01,' indicating the resident was…

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 housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by expired nutritional food items such as seven (7) of nine (9) eight-ounce containers of Jevity, 1.5 calories nutritional drinks that expired on May 2022, two (2) of nine (9) eight-ounce containers of Jevity, 1.5 calories nutritional drinks that expired on May 2023, six (6) of six (6) eight-ounce Osmolite nutritional drinks that expired on August 1, 2023, 19 of 19 eight fluid ounce containers of Jevity, 1.5 calories nutritional drinks that expired on November 1, 2021, and six (6) of six (6) eight fluid ounce containers of Nestle boost nutritional drinks that expired on August 19, 2023, that were stored on three (3) of eight (8) resident care units. During an environmental walkthrough of the facility on July 10, 2023, between 10:00 AM and 4:00 PM the following were observed: In the pantry of unit 1 Orange, seven (7) of nine (9) eight-ounce containers of Jevity, 1.5 calories nutritional drinks were expired as of May…

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) out of 42 sampled residents, facility staff failed to accurately code the Minimum Data Set (MDS) assessment for resident #125 for dialysis, and resident #37 for a fall. The findings included: 1.Facility staff failed to accurately code Resident #125's dependent on Dialysis Resident #125 was admitted on [DATE] with multiple diagnoses including Hypertension, Diabetes Mellitus 2, and End-stage renal disease dependent on Dialysis. Reviewed admission progress note dated 5/19/2022 at 05:10 PM documentation showed that the resident receives dialysis treatment (M [Monday] -W [Wednesday -F [Friday]) in-house from Davita Dialysis. Review of the admission (MDS) Minimum Data Set assessment dated [DATE] showed that facility staff coded the following: In Section C (Cognitive Patterns), a Brief Interview for Mental Status (BIMS) summary score of 15, indicates intact cognition. In Section O (Special Treatments, Procedures, and Programs) O0100 Check all of the following…

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 interview, and staff interview, the facility's staff failed to develop a care plan how staff were to address Resident #90 sexual inappropriateness toward Resident #16 on 09/03/22 and failed to implement approaches to monitor and record Resident #124's complaint of pain as indicated on the comprehensive care plan. Residents #90 and #124 The findings included: 1. Resident #90 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including Alcohol Use. A nursing note dated 09/03/22 12:31 AM [Recorded as Late Entry on 09/06/22 12:49 AM] documented the following but not limited to, At around 2:35 AM call light was on in room [ROOM NUMBER]A, when caregiver [Employee #12, Certified Nursing Assistant] went there. Care giver called the nurse [Employee #13, Licensed Practical Nurse] and reported that he saw [Resident #90] kissing [Resident #16]. By the time the nurse went there [Resident #90] was leaving the room. A unit manager's [Employee # 18] progress…

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, the facility's staff failed to identify and eliminate environmental hazards (nonfunctioning alarm on exit door) and maintain consistent supervision and surveillance of Resident #144, who subsequently gained access to elope through a broken patio door. The findings included: A facility policy titled 'Resident Elopement' documented, The facility is responsible for being knowledgeable of the location of all residents at all times. Resident #144 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Human Immunodeficiency Virus (HIV) Disease, History of Fall with Fractur of Right Radius and Glaucoma. A nursing progress note dated [DATE] AT 8:53 PM documented, Upon admission, resident was observed going toward the elevator and she will not stay in her room or sit still. She was re-directed several times. A Physician order dated [DATE] documented, Elopement risk assessment on admission and Hourly rounding. An Elopement Risk…

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, record review and staff interviews, facility staff failed to develop a narcotic count sheet that identified two (2) licensed nurses to reconcile the resident's narcotic medications. The findings included: A document titled 'Daily Narcotic count QA (quality assurance) data analysis report form' documented, Month August 2023 and Off-going no holes On-coming no holes and All narcotic count sheets must have incoming and outgoing nurse signatures every shift. A review of a document titled 'Shift Verification of Accuracy of Controlled Drug Record' documented, August 2023 with the following data: Unit One Brookland: 08/01/23, 08/04/23, 08/09/23, 08/12/23, 08/13/23, 08/14/23, 08/15/23, 08/16/23, 08/20/23, 08/21/23, 08/23/23, 08/25/23, 08/26/23, 08/27/23, 08/28/23 and 08/30/23 documented, Day shift beginning at 7 AM, Evening shift beginning at 3PM and Night shift beginning at 11 PM, the on duty nurse and off duty nurse signatures were the same for consecutive shifts indicating there was no second licensed nurse present to verify the accuracy of the resident's controlled…

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 food items such as one (1) of one (1) bag of shredded carrots, approximately 50 of 50 containers of apple sauce and approximately 120 cold sandwiches of tuna, turkey and cheese, ham and cheese, and/or peanut butter that were observed undated in one (1) of one (1) walk-in refrigerator, one (1) of (1) bag of provolone cheese in reach-in refrigerator #2 that was not labeled, and two (2) of two (2) open packs of yellow cheese in the cook refrigerator that also was not labeled or dated. The findings include: During a tour of dietary services on August 20, 2023, at approximately 6:30 AM, food items including one (1) of one (1) bag of shredded carrots, approximately 50 of 50 containers of apple sauce and approximately 120 cold sandwiches of tuna, turkey and cheese, ham, and cheese, and/or peanut butter observed in one (1) of one (1) walk-in refrigerator were not labeled or dated. Employee #39 acknowledged the findings during a face-to-face interview on August 22,…

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 one (1) of 42 sampled residents, facility staff failed to show documented evidence that Resident #20's Humalog insulin was administered as ordered by the physician to treat finger stick blood glucose results greater than 250mg (milligram)/dl (deciliter). The findings included: Resident #20 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Diabetes Mellitus, Hypertension and Atherosclerotic Heart Disease. Review of Resident #20's medical record revealed: A Physician order dated 10/27/22 documented, Humalog U(unit)-100 Insulin (insulin lispro) solution; 100 unit/mL (milliliter); amt (amount): 3 units; subcutaneous Special Instructions: Fingersticks AC (before meals) and HS (at bedtime), give 3 units of Humalog Insulin Subq (subcutaneous) if BS (blood sugar) > (greater than) 250 Call MD (medical doctor)/NP (nurse practitioner) if BS < (less than) or > 400 for DM (Diabetes Mellitus) Before Meals and At Bedtime; 07:30…

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 reviews and staff interviews, the facility's staff failed to ensure that the comprehensive Quality Assurance and Performance Improvement (QAPI) plan was implemented to correct identified deficiencies related to implementing abuse policy, reporting allegation of abuse, or thoroughly investigating abuse. The resident census on the first day of the survey was 170. The findings included: A review of the facility's complaint/facility reported incident survey that ended on 05/18/23 showed that the facility was cited for the following deficiencies: F607, F609, and F610- Freedom from Abuse, Neglect, and Exploitation. An onsite recertification, complaint, and facility reported incident survey was conducted from 08/20/23 to 09/14/23. The onsite survey determined the facility remained out of compliance. The facility submitted a plan of correction for the complaint/facility reported incident survey dated 05/18/23 survey and alleged compliance as of 07/31/23. The facility's accepted plan of correction for F607, F609, and F610 included the following: F607 - Implement Abuse Policy…

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 five (5) of 56 sampled residents, facility staff failed to accurately code the Minimum Data Set for one (1) resident who had episodes of anxiety; one (1) resident having impairment on one side; one (1) resident for dialysis; one (1) resident for shortness of breath, and for one (1) resident for discharge assessment. Residents' #60, #100, #134, #179 and #181. The findings include: 1. Resident #60 was admitted to the facility on [DATE], with diagnoses that included: Peripheral Vascular Disease, Traumatic Brain Injury, Chronic Pain, Contracture, Gastrostomy Status and Mild Cognitive Impairment. Review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed: Section C (Cognition) Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired. Section E (Behavior) Delusions (misconceptions or beliefs that are firmly held, contrary to reality) is documented. Review of the physician's orders revealed the following: 7/21/2020…

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 56 sampled residents, facility staff failed to ensure that residents received treatment and care in accordance with professional standards of practice as evidence by: failure to follow the hospital discharge instructions to continue the administration of an antibiotic for two days to treat one (1) resident with a diagnosis of a urinary tract infection, and to apply the palm guard to one (1) resident's left hand in accordance with the physician's order. Residents' #29 and #100. The findings include: 1. Facility staff failed to ensure that hospital discharge instructions to continue antibiotic for two days (01/13/21 and 01/14/21) was acted upon in a timely manner. Resident #29 was admitted to the facility on [DATE], with diagnoses, which included Hypertension, Diabetes Mellitus 2, Hyperlipidemia, Hypothyroidism, Chronic Obstructive Pulmonary Disease, Cerebrovascular Accident, Seizure and Dementia. Review of the Hospital Discharge summary 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, facility staff failed to: complete the residents Medication Regiment Review (MRR) assessment in accordance with accepted professional standards of practice for three (3) residents, to ensure one (1) residents History and Physical was dated on completion and failed to document the correct dialysis access location for one (1) resident. Residents' #7, #60, #148, #162, and #177. The findings include: Review of the facility policy entitled, Consultant Pharmacist Services revealed, .Reviewing the medication regimen of each resident at least monthly, complying with Federal, State, and Local mandated standards of care in addition to other applicable standards, and documenting the review and findings in consulting software . 1. Facility staff failed to complete MRR assessment in accordance with professional standards of practice. A. Resident #7 was admitted to the facility on [DATE] with multiple diagnoses, including Hypothyroidism, Dementia without Behaviors, Anxiety, 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.

Based on observation and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by call bells that failed to initiate an audible or visual alarm when tested in five (5) of 46 resident's rooms. The findings include: During an environmental walkthrough of the facility on 06/15/2021, at approximately 10:00 AM, call bell in five (5) of 46 resident's rooms did not emit an audible or visual alarm when tested. (rooms #314, #353, #361, #364, #379). This breakdown could prevent or delay care to residents in an emergency. During a face-to-face interview on 06/16/2021, at approximately 10:00 AM, Employee #5 (Engineer Manager) acknowledged the findings and stated they had already been corrected.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, facility staff failed to provide housekeeping and maintenance services necessary to maintain a safe, clean, comfortable environment as evidenced by a loose privacy curtain bracket in one (1) of 46 resident's rooms, stained ceiling tiles in one (1) of 46 resident's rooms, and two (2) of five (5) ceiling vents that lacked a cover in the hallway of unit 2 Orange. The findings include: During an environmental walkthrough of the facility on 06/15/2021, at approximately 10:00 AM: 1. The privacy curtain holder (bracket) in resident room [ROOM NUMBER] was noted to be loose, one (1) of 46 resident's rooms. 2. Ceiling tiles were stained in resident room [ROOM NUMBER], one (1) of 46 resident's rooms. 3. Two (2) of five (5) ceiling vent covers were missing in the hallway near resident rooms #257 and #261 on unit 2 Orange. During a face-to-face interview on 06/16/2021, at approximately 10:00 AM, Employee #5 acknowledged the findings and stated they had already been corrected.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interviews, facility staff failed to ensure all required documents were conveyed to the receiving health care provider for two (2) of 56 sampled residents that were transferred from the facility to the hospital. Residents' #148 and #161. The findings include: Review of, Stoddard Baptist Global Care -Documents to be included in transfer packet list the following items: History and Physical signed, Current Medications Lists (POS [physical order sheet]); face sheet, Last physician notes; labs/microbiology/cultures (3 months); Facility transfer form; Guardianship/legal documents; Transfer order; DC (District of Columbia)-DNR (Do Not Resuscitate) comfort care; Problem List; and Advance Directives. The facility has a protocol for staff to complete a checklist before transferring residents. However, the form does not list Comprehensive Care Plan Goals as a document to be sent to the receiving facilities. 1. Resident #148 was admitted to the facility on [DATE], with diagnoses 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, the facility staff failed to provide residents and residents representatives with Notice of Discharge, Transfer or Relocation and the written Notices of a Statement of Appeal for two (2) of 56 sampled residents that were transferred to the hospital. Resident's #129 and #161. The findings include: 1. Resident #129 was admitted to the facility on [DATE] with multiple diagnoses, including Wandering, Hypertension, Type 2 Diabetes, and Chronic Kidney Failure. A review of the resident's medical record revealed: 04/27/21 at 11:51 PM [Nursing Note] documented, .This writer calls to the hallway near room [ROOM NUMBER]A by nursing assistants and observed resident lying on her right side on the floor at about 5:00 PM .resident noted with small swelling/small abrasion to her right temple area of the head with little bleeding noted at the site .NP(nurse practitioner) order resident to be transfer to the nearest ER (emergency room) for further evaluation .transferred resident to…

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 staff failed to provide written information to the resident or resident representative that explained the duration of their bed-hold for one (1) of 56 sampled residents that were transferred to the hospital. Resident #148. The findings include: Resident #148 was admitted to the facility on [DATE], with diagnoses Unspecified Dementia Without Behavioral Disturbance, Glaucoma, Ascarasis Pneumonia, Type 2 Diabetes Mellitus Without Complications, Hypertension, and Epilepsy. Review of the medical record revealed: Nurse progress note dated 3/16/21, .about 2:15 pm resident was observed not responding to name call and simple commands. He was leaning towards his right hand; right hand was shaking but breathing and have palpable pulse .NP (Nurse Practitioner) order given to transfer resident via 911 to the nearest ER (emergency room) for further evaluation of unresponsiveness . Physician's order dated 3/16/21, Transfer resident via 911 for further evaluation 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 56 sampled residents, facility staff failed to update a resident's care plan to address one (1) resident with iron deficiency-anemia to include person-centered measurable objectives and time frames and for one (1) resident with a perm-a-cath access site for dialysis treatment. Residents' #99 and #134. The findings include: 1.Facility staff failed to update Resident #99's iron deficiency anemia care plan to include person-centered measurable objectives and time frames. Resident #99 was admitted to the facility on [DATE], with diagnoses that included: Anemia, Hypertension, Renal Insufficiency, Viral Hepatitis C, Diabetes Mellitus, Depression and Chronic Obstructive Pulmonary Disease (COPD). Review of the physician's orders revealed the following: 06/02/21 Ferrous sulfate tablet, delayed release 325 mg (milligram) . administer 1 tablet by mouth daily for anemia . 6/7/21 CBC [complete blood count] on Mondays . 06/09/2021 Head to toe skin observation for 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interview, the facility staff failed to provide an environment free from accident hazards as evidenced by surge protectors that were observed in use, on the floor of two (2) of 46 resident's rooms and an extension cord that was observed in one (1) of 46 resident's rooms. The findings include: 1. Surge protectors were observed in use, on the floor of resident's room [ROOM NUMBER] and #320, two (2) of 46 resident's rooms. 2. An extension cord was observed in use, in one (1) of 46 resident's rooms resident room. (#377). During a face-to-face interview on 06/16/2021, at approximately 10:00 AM, Employee #5 (Engineer Manager) acknowledged the findings and stated they had already been corrected.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff interview, for three (3) of 56 sampled residents, facility staff failed to conduct a Medication Regimen Review (MRR) at least monthly. Residents' #60, #162 and #177. The findings include: Review of the facility's policy entitled, Consultant Pharmacist Services revealed, . Reviewing the medication regimen of each resident at least monthly, complying with Federal, State, and Local mandated standards of care in addition to other applicable standards, and documenting the review and findings in consulting software . 1. Resident #60 was admitted to the facility on [DATE], with diagnoses that included: Peripheral Vascular Disease, Traumatic Brain Injury, Chronic Pain, Contracture, Gastrostomy Status and Mild Cognitive Impairment. Review of Resident #60's record revealed that there was no MRR done for the month of May 2021. During a telephone interview conducted on 06/16/2021, at 1:06 PM, Employee #10 (Pharmacist) stated, I am not sure if I have a MRR for this resident for May. I do 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 interview, for two (2) of 56 sampled residents, facility staff failed to promptly notify the ordering physician of laboratory results that fall outside of a clinical reference range in accordance with facility policies and procedures for notification. Residents' #7 and #99. The findings include: Review of the facility's policy entitled, Documentation Requirements, item #12 Laboratory, X-rays, and other tests, revealed, Results of laboratory and x-ray studies are documented in the record. It is documented by a licensed nurse that the attending physician was notified of the abnormal results. Review of the facility's policy entitled, Lab Results, revealed, . Once the physician has been notified, a notation must be made on the lab slip regarding date, time, signature of reporting person and a brief description of orders, if any; followed by documentation in the clinical record . 1. Resident #7 was admitted to the facility on [DATE], with multiple diagnoses, including Hypothyroidism,…

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, on three (3) of three (3) observations, facility staff failed to maintain infection control and prevention practices in accordance with standards of practice to minimize the potential spread of infections. The findings included: 1. Review of the facility's policy entitled, Occupied Resident Isolation Room Cleaning- Contact, Strict Contact and Droplet Isolations revealed, Reline all trash liners. During a tour of room [ROOM NUMBER] on unit 2 Orange on 06/14/2021, at 2:30 PM, a red trash can was observed with no trash bag, with used discarded personal protective equipment inside. It should be noted that room [ROOM NUMBER] is on the COVID-19 observation unit where strict contact and droplet transmission-based precautions were in place. During a face-to-face interview conducted on 06/14/2021, at 2:35 PM, Employee #11 (Registered Nurse) stated, I am not sure who put the items in the trash can. They shouldn't have put any trash inside without a trash bag. 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.