FT Washington Rehabilitation and Wellness Center

Based on observation, record review, and interview, it was determined that the facility failed to administer the correct ordered medication form, follow professional standards of nursing practice and use appropriate infection control practices during medication administration. This was evident for 1 (Resident #90) of 5 residents observed during the medication administration task.The findings include:On 11/20/2025 at 8:52 AM, during the medication administration observation, Registered Nurse (RN #1), removed a pill from the bubble pack and placed it in a 2 oz clear souffle cup with the other medications. After realizing that he/she already placed the same pill in the cup, he/she used fingers to pick up a tablet and returned it to the bubble pack. He/she then crushed the following medications of Resident #90 along with other medications in 2 separate plastics for pill crusher:1. 1 tablet of Aspirin 81 mg enteric coated tablet, however the Physician's order indicated that Aspirin was to be administered in a chewable form.2. 1 tablet of Ferrous sulfate delayed release 325 (65 Fe) MG…

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, interviews and medical record review, it was determined the facility failed to ensure that a dependent resident was properly groomed. This was evident for 1 (Resident #18) of 5 residents reviewed for ADLs care during the survey process.The findings include:Activities of Daily Living (ADLs) are activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating.On 11/17/25 at 11:07 AM the surveyor observed Resident #18 lying in bed. The resident's fingers on both hands were contracted and bent towards each other. His/her fingernails were approximately 1/2 inch long and visibly dirty with dark substances underneath both thumbs and fingers.On 11/18/25 at 11:30 AM the surveyor reviewed the Resdent#18's care plan which was revised on 04/28/25. The care plan stated, ADL Self Care Performance deficit, requires assistance with ADL, Cognitive deficit, . Also, Resident #18's MDS assessment dated [DATE] Section…

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 interview, review of a complaint, and record review, it was determined that the facility failed to provide treatment/services to maintain vision. This is evident for 1 (Resident #130) of 2 residents reviewed for communication and sensory problems during the recertification and complaint survey.The findings include:Latanoprost a prescription eye drop medication used to treat eye conditions like glaucoma and ocular hypertension by lowering high pressure inside the eyeball. It works by essentially opening up or relaxing the eye's natural drainage pathways, allowing more fluid to flow out of the eye and into the bloodstream. If the high pressure is left untreated, it can damage the optic nerve and lead to permanent vision loss. On 11/19/2025 at 8:14 AM, Resident #130 stated that he/she could not see clearly even with eyeglasses on. He/she added that this has been going on for several months and was bothering him/her. He/she confirmed being seen by an eye doctor in October but unsure if the facility was addressing the concern. On 11/19/25 at 5:21 PM, a review of complaint…

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, interview and record review, it was determined that the facility failed to provide necessary respiratory care services by failing to label oxygen administration equipment. This was evident for 1 (Resident #163) of 1 resident reviewed for respiratory care during the recertification survey.The findings include: Oxygen therapy is a treatment that provides a person with extra oxygen to breathe in. It is also called supplemental oxygen. A nasal cannula is a thin, flexible tube that delivers oxygen through the nose. A humidifier in oxygen therapy is a device that adds moisture to dry, concentrated oxygen to prevent drying and irritation of a patient's nasal passages, throat, and lungs. These humidifiers typically consist of a bottle filled with water that attaches to an oxygen concentrator. On 11/17/25 at 11:15 AM, Resident #163 was observed receiving oxygen therapy via nasal cannula, however, the oxygen tubing and the humidifier bottle were not labeled with the date they were put into use or the date they should be replaced. On 11/17/2025 at 11:19 AM, the Director…

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 clinical record review and staff interviews, it was determined that the facility failed to act upon a clinically significant medication irregularity identified by the consultant pharmacist for residents. This was evident for 1 (Resident #5) out of 5 residents reviewed for medication regimen review during the annual survey.The findings include:On 11/25/25 at 10:02 AM, a review of Resident #5's clinical record revealed a Medication Regimen Review (MRR) dated 8/11/25 that identified a clinically significant drug interaction between Eliquis 5 mg twice daily and Paxlovid. The consultant pharmacist recommended reducing the Eliquis dose by 50% during Paxlovid therapy and continuing the reduced dose for 3 days after the last Paxlovid dose due to increased bleeding risk. The physician response section of the report was blank. Continued review revealed no documentation that the recommendation was addressed by the physician, the nursing staff, or the Director of Nursing (DON). On 11/25/25 at 10:23 AM, a review of Resident #5's August 2025 Medication Administration Record (MAR)…

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, interview and record review, it was determined that the facility failed to ensure a medication error rate of less than 5% during the medication observation task. This was evident for 4 of 25 medications administered during the observation which resulted in a medication error rate of 16%.The findings include:On 11/20/2025 at 8:52 AM, during the medication administration observation, Registered Nurse (RN #1), crushed the following medications of Resident #90 along with other medications in 2 separate plastics for pill crusher and mixed them in apple sauce:1. 1 tablet of Aspirin 81 mg enteric coated tablet, however the Physician's order indicated that Aspirin was to be administered in a chewable form.2. 1 tablet of Ferrous sulfate delayed release 325 (65 Fe) MG (Ferrous Sulfate) tablet3. 2 tablets of Levetiracetam 750 mg tablet4. 1 tablet of Metformin 500 mg tablet RN #1 stated that Resident #90 preferred to take the medications in powdered form and mixed in apple sauce.On 11/20/2025 at 9:11 AM, while RN #1 was administering the crushed medication mixture,…

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 interview, record review and observation, it was determined that the facility failed to provide dental services for residents. This was evident for 2 (Resident #13 and #122) of 2 residents reviewed for dental services during the recertification survey.The findings include: 1) During an interview with a family member for Resident #13 on 11/18/2025 at 5:43 PM he/she reported that the resident has had problems with his/her teeth and had not had any dental care. During a review of medical records for Resident #13 on 11/20/2025 at 10:26 AM it revealed that he/she had a history of dementia and was dependent on staff for care. A change in condition communication form dated 11/21/2023 was found which reported that the nurse had found Resident #13 chewing on his/her tooth that came off and the nurse noted the resident is cognitively impaired. During further review of Resident #13 medical records it was discovered that an order was placed on 11/21/23 that ordered a Dental consult secondary to his/her tooth that came out and discontinue order when consult is completed. During…

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 interviews, it was determined that the facility failed to maintain 1) Food service equipment in a manner that ensures sanitary food service operations and 2) Proper sanitation for the storage of food on the nursing units. This was evident during the initial tour of the kitchen and on 1of 3 nursing units observed for food storage and sanitation.The findings include:1. On 11/17/25 at 7:59 AM during an initial tour of the kitchen with the Certified Dietary Manager (CDM), the surveyor observed on the wall outside the walk-in refrigerator a temperature log which stated 36 degrees 11/17/25 AM. The surveyor observed that the thermometer inside the refrigerator was broken and not functioning. When asked how the temperature was verified when the thermometer was broken, the CDM stated that the temperature could have been recorded before the thermometer was broken. The thermometer was replaced. Later at 8:30AM the refrigerator's temperature revealed 39 degrees Fahrenheit.The log on the wall outside the walk-in freezer read -1 degree 11/17/25 AM. There was no…

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 interviews, it was determined that the facility failed to provide a therapy screening for 1 (Resident #17) of 28 residents reviewed for therapy services during the annual survey.The findings include:During a review of medical records for Resident #17 on 11/21/2025 at 9:02 AM it was discovered that the Resident had mobility difficulties and a history of falls. A change in condition form dated 9/29/2025 revealed that the Resident was found on the floor laying on his/her back after an unwitnessed fall.During a continued review of medical records it was revealed that there was a Nursing Referral to Therapy form completed on 9/30/2025 as a result of Resident #17 having an Unwitnessed fall.During further record review it was discovered that no therapy assessment or evaluation had been completed on Resident #17 after the fall and the nursing referral.During an interview with Therapy Manager #17 on 11/21/2025 at 2:56 PM she reported that the nurses can use the Therapy Notification Referral if they see any kind of decline or concerns with the residents. She…

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 review of facility documents and staff interview it was determined the facility failed to report an allegation of abuse immediately but not later than 2 hours after an allegation was made. This was evident for 1 (Resident #16) of 13 residents reviewed for a facility reported incident during the complaint survey.The findings include: On 8/4/25 at 2:32 PM, a review of facility reported incident 294211 alleged a male staff member had exposed himself to Resident #16. The facility's investigation documented the facility became aware of the incident on 10/20/24 at 8:00 AM.Review of facility documentation revealed an email confirmation that documented the facility's initial report was sent to the State Survey Agency on 10/20/24 at 11:21 AM. The facility failed to report the allegation of abuse immediately, but not later than 2 hours after the allegation was made.The concerns with the late reporting of an allegation of abuse was discussed with the Nursing Home Administer (NHA) on 8/5/25 at 9:45 AM. The NHA acknowledged the concerns at that time and indicated he would look into 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 medical record review and staff interview, it was determined that the facility staff failed to ensure that each resident received treatment and care in accordance with professional standards of practice by 1) failing to ensure orders for the resident's immediate care were confirmed with the physician and documented in the medical record, 2) failing to reconcile a resident's medications on admission, 3) failing to ensure medication was available in a timely manner for the facility to administer, and 4) failing to notify the physician when a resident was not given medication as prescribed. This was evident for 1 (Resident #20) of 16 residents reviewed for a complaint.The findings include:Respite care is either planned care or temporary emergency healthcare that is provided to the caregiver of a child patient or adult patient.Medication Reconciliation is the process of identifying the most accurate list of all medications that the patient is taking by comparing the medical record to an external list 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 observation, medical record review, and staff interview, it was determined that prior to the installation of bed rails, the facility 1) failed to identify and use appropriate alternatives prior to installing or using bed rails, 2) failed to ensure the risks and benefits of bed rails were reviewed with the resident or resident representative and obtain informed consent for use of the bed rails, 3) failed to obtain a physician's order for the use of the bed rails and 4) failed develop a care plan with specific interventions for use of the bed rail. This was evident for 3 (Resident #8, #11, #28) of 3 residents reviewed for bed rails during the complaint survey.The findings include: Bed rails (side rails) are adjustable bars that attach to the bed and available in a variety of types, shapes, and sizes. As enablers, bedrails facilitate movement and may promote independence. Entrapment is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail.A care plan is a guide that addresses the unique needs of each resident. It is used to plan,…

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 medical record review and staff interview, it was determined the facility failed to ensure the provision of physician services 24 hours a day, in case of emergency. This was evident for 1 (Resident #14) of 16 residents reviewed for a complaint during the complaint survey.The findings include: Telehealth is the delivery of health services remotely, using technology to connect patients and providers who are not in the same physical location.On 7/31/25 at 12:08 PM, complaint #294220 reviewed alleged that on 2/9/25 the resident's representative received a call from Resident #14 complaining of continued severe stomach pain and the resident had requested to go to the emergency room (ER). The complaint alleged the resident's representative received a call from the facility informing him/her that the staff could not get in touch with the on-call doctor, and the resident wasn't in distress, therefore, if the representative wanted Resident #14 transported to the hospital ER, then then s/he would have to transport the resident to the ER. On 8/6/25 at 12:00 PM, a review of Resident…

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 resident record review and staff interview, it was determined that the facility staff failed to ensure residents were either admitted with an Advance Directive or offered one at the time of admission. This was evident for 4 (#9, #63, #64 and #118) out of 11 residents reviewed for Advance Directives. Advance directives are legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes. The two most common advance directives for health care are the living will and the durable power of attorney for health care. The findings include: 1a. A review of Resident #63's clinical record on 1/11/24 at 12:39 PM revealed that an Advance Directive was not in the chart nor was there a progress note written with any mention that an Advance Directive was offered. 1b. A review of Resident #64's clinical record on 1/08/24 at 11:02 AM revealed that an Advance Directive was not in the chart nor was there a progress note written with any mention that an Advance Directive was offered. 1c. A review of Resident #118's clinical record on…

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

Based on observations and interviews, it was determined that the facility failed to provide residents with a safe and homelike environment. This was evident for 6 (Resident #3, #8, #44, #67, #108 and #119) out of 66 residents' rooms and shared spaces observed during multiple tours of the facility during annual survey. The findings include: 1. On 1/9/24 at 9:30 AM Surveyors conducted a tour of the facility and observed: - A sink in Resident #3 room with a rusted hole in the basin measuring approximately 3 inches in diameter, with sharp edges at the interior of the hole. - The door to the shared closet in Resident #3's room was off track and uneven in appearance. - A wooden bed bumper located on the wall directly behind Resident #3's bed was visibly broken and splintered. - The privacy curtains in Resident #8's room were visibly damaged with two sets of holes on the netted portion of the curtain. On 1/10/24 at 11:00 AM Surveyors conducted an additional tour of the facility and observed: - A wooden bed bumper located on the wall directly behind Resident #119's bed was visibly broken…

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 interviews, and record review, it was determined that the facility failed to: 1) ensure the resident and/or families are invited to care plan meetings (Resident #89), 2) review and revise a Resident's care plan by a complete interdisciplinary team and after each quarterly and comprehensive assessment (Resident #22, #75, #113 #41), and 3) facilitate timely care plan conferences after a resident' s quarterly assessment to allow the resident and resident representative to participate in the care planning process (Resident #110). This was found evident for 6 (#22, #75, #113, #110, #41 and #89) out of 8 Residents reviewed for care planning during an annual and complaint survey. The findings include: 1. Resident #89 was interviewed on 1/10/24 at 9:22 AM. The resident stated that they do not go to their care plan meetings, but their son goes. The clinical record was reviewed on 1/10/24 and it was revealed that there was no evidence that the resident or son has been invited to the most recent care plan meeting.…

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 interviews and observation, the facility failed to ensure food was served at a palatable temperature. This was found to be evident for 6 (#70, #75, #89, #97, #119, #108) out of 66 residents interviewed during the survey. The findings include: During the initial screening of the residents, the surveyors received palatable and/or cold food comments from the following residents. Resident #75 reported on 01/09/24 at 08:19 AM, the food is cold and dried out like it has been sitting there. On 01/09/24 at 09:22 AM, Resident #70 stated the food is not good. Resident #89 on 01/10/24 at 09:25 AM reported that the food is blah and not nutritious. On 01/10/24 at 10:17 AM, Resident #97 reported that food is warm on the 3rd floor but cold on the 1st floor. Resident # 119 reported cold food on 01/10/24 at 10:48 AM. Resident #108 told the surveyor on 01/10/24 at 11:00 AM, that he receives cold food. On 1/18/24 at 11:45 AM the surveyors observed the holding temps of food in the kitchen. Food temps on the steam table ranged from 140 degrees to 170 degrees, however based on a temperature…

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 interview with staff, it was determined that the facility failed to store food and in a manner that maintains professional standards of food service safety. This practice had the potential to affect all residents eating food prepared in the facility's kitchen. The findings include: On 1/8/24 at 7:50 AM, during the initial tour of the kitchen with Dietary Director #9, the surveyor inspected a walk-in refrigerator/freezer. The surveyor observed an open container of chopped garlic that was dated when received but not when opened or when to discard. The Dietary Director #9 stated that the garlic was just opened but should be labeled with the date when opened and a discard date. There was also a jar of mayonnaise that was labeled as opened 11/30/23 and discard 12/30/24. The Dietary Director #9 stated the mayonnaise should be labeled to discard 3 months after the open date. She further stated she would discard both containers and reeducate her staff. During a revisit to the kitchen on 01/11/24 on 10:17 AM, the surveyor noted that all food was dated when opened or…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and observations, it was determined that the facility failed to provide a dignified experience for a Resident during Activities of Daily Living (ADL) cares. This was found evident of 1 Resident (Resident #22) on a random observation during the initial tour. The findings include: On 1/8/24 at 11:24 AM, the surveyor observed a Geriatric Nurse Assistant (GNA) Staff #28 pushing Resident #22 out of his/her room into the hallway in a wheelchair. The surveyor then asked Staff #28 where she was taking the Resident and also what was his/her name. Staff #28 stated she was taking Resident #22 to the shower but did not know his/her name. They surveyor asked if she was signed to work with Resident #22. Staff #28 stated she was, however, she normally doesn't work in this area. The surveyor next observed Staff #28 stop Nurse Practitioner Staff #6, who was passing in the hallway, and asked her to identify Resident #22. On 1/8/24 at 1:35 PM, the surveyor interviewed Unit Manager Staff #29. During the interview…

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 interview with staff, it was determined that the facility failed to ensure a resident's right to communicate their needs and to receive treatment, care, and services that promote the maintenance of one's own quality of life. This was evident for 1 (Resident #388) out of 1 residents investigated for self determination. The findings include: On 1/9/2024 at 9:30AM during a tour of the first floor nursing unit, the Surveyors observed Resident #388 sitting in a wheelchair in the hallway by his/her room. The resident approached the Surveyors in the hallway and stated that the facility had not given me my medication [Immunocompromised Deficiency medication] and that he/she would like to speak with his/her care coordinator. The resident appeared confused and upset. On 1/9/2024 at approximately 12:30PM, during a review of Resident #388's electronic medical record, the Surveyors discovered the resident was admitted on [DATE] from the hospital. During further review of Resident…

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 interview, it was determined that the facility failed to accurately document wound assessments in a resident's medical record. This was found evident of 1 (Resident # 12) of 6 Residents reviewed for pressure ulcers. The findings include: On 1/12/24 at 8:08 AM, the surveyor reviewed Resident #12's medical record. The review revealed a Minimum Data Set (MDS) assessment that documented that Resident #12 entered into the facility with one stage 4 (classification of wound; stage 4 is a wound that is deep in the tissue with exposed bone, tendon and/or muscle) pressure ulcer. Once a stage 4 wound is documented on the MDS assessment it is always classified as stage 4 but may be documented with a notation that it is healing to lower to a lower stage. On further review the surveyor noted a MDS assessment that was completed on 7/20/23. This assessment documented that Resident #12 had zero stage 4 pressure ulcers and had one stage 3 pressure ulcer that was not present on admission. The next MDS assessment reviewed was the most up-to-date MDS assessment completed on…

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

Based on interview and record review, it was determined that the facility failed to assist a Resident that required replacement of hearing aids with services for replacement. This was found evident for 1 (Resident #41) of 4 Residents reviewed for hearing and vision during an annual survey. The findings include: On 2/1/24 at 11:23 AM, the surveyor interviewed the spouse of Resident #41. During the interview Resident #41's spouse discussed concerns that Resident #41's hearing aids were lost and the staff had not followed up in regards to a plan to obtain new hearing aids. On 2/1/24 at 1:01 AM, the surveyor interviewed Licensed Practical Nurse (LPN) Staff #17. During the interview, Staff #17 stated she recalled the day she noticed Resident #41' hearing aids were missing. She reported she had the previous day off and noticed the morning she returned to work that Resident #41 did not have his/her hearing aids. The unit manager was aware, and she remembers writing a statement. On 2/2/24 at 7:55 AM, the surveyor interviewed the Director of Nursing (DON). The DON stated she was aware 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.

Past Non-compliance Based on clinical record review, staff interview, and an investigation into a complaint it was determined that the facility staff failed to ensure residents were free of accidents. This was evident for 1 (#188) out of the 66 residents reviewed as part of the survey process. The findings include: A review of complaint intake MD00201193 on 2/1/24 revealed that the resident had a fall on 9/25/23. The facility timeline of events included: On 9/25/23 at 7:53 AM, the assigned Geriatric Nursing Assistant (GNA) was providing Activities of Daily Living (ADL) care to the resident. GNA stated that the resident would normally roll on one side and hold onto the edge of the mattress while care was provided. GNA was standing on the left side of the bed. The resident suddenly let go of the mattress and fell to the floor. The GNA attempted to rush around the bed to catch the resident but could not. GNA called for help. A nurse entered the room and helped the GNA with getting the resident back into bed. The resident did not complain of pain and showed no signs of injury. A review…

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 interview with staff, it was determined that the facility failed to ensure that a resident had orders in place to maintain immediate care needs including: 1.) an order to turn and reposition every two hours for a resident with pressure injuries (Resident #111). 2.) an order for no blood pressure readings in the access limb of a hemodialysis resident (Resident #110), and 3.) a completed MOLST (Resident #74). This was found to be evident for 3 (Resident #111, #110, & #74) out of 66 residents reviewed for physician services. The findings include: Pressure injury: Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or…

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

Based on clinical record review and staff interview, it was determined that the facility staff failed to ensure a resident's medication orders were followed. This was evident for 1 (#63) out 5 residents that were selected for Medication Regimen review. The findings include: A review of Resident #63's clinical record on 1/26/24 revealed the resident was ordered Midodrine 10 mg three times a day for hypotension. Hold for systolic blood pressure (first number- SBP) greater than 120. A review of the December 2023 Medication Administration Record (MAR) revealed that on 12/5/23 in the afternoon the resident had a SBP of 123 but was still administered the medication. On 12/20/23 in the afternoon the resident had a SBP of 125 but was still administered the medication. On 1/6/24 in the morning the resident had a SBP of 126 but was still administered the medication. The Director of Nursing (DON) was interviewed on 2/1/24 at 10:20 AM. She agreed the medications needed to be held but weren't. She said she would verify the codes for two additional days. One was coded as 5 and the other as 9. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview with staff, it was determined that the facility failed to accurately document an admission assessment within a resident's medical record. This was evident for 1 (Resident #117) out of 66 residents investigated during the annual survey. The findings include: Type 2 Diabetes Mellitus is a long term condition in which your body has trouble controlling blood sugar and using it for energy. End Stage Renal Disease (ESRD) is a medical condition in which a person's kidneys cease to function on a permanent basis leading to the need for long term dialysis or kidney transplant to maintain life. Hemodialysis (HD) is a treatment, using a dialysis machine, to filter wastes and water from your blood when your kidneys are no longer healthy enough to do so. On 1/24/24 at 12:00 PM, during record review, the Surveyor discovered that Resident #117 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (T2DM), end stage renal disease (ESRD), dependence on renal…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, it was determined that the facility failed to: 1.) ensure that transmission-based precautions were followed by facility staff. This was evident for 1 (Staff #32) out of 1 staff observed during Covid testing, and 2.) maintain practices to help prevent the transmission of infections.This was evident for 1 of 2 meal tray observations completed on an annual and complaint survey. The findings include: Transmission-based precautions refer to actions (precautions) implemented in addition to standard precautions that are based upon the means of transmission (airborne, contact, and droplet) in order to prevent or control infections. Droplet precautions refer to actions designed to reduce/prevent the transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Contact precautions refer to measures that are intended to prevent transmission of infectious agents which are spread by direct or indirect contact 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.

Based on interview and record reviews, it was determined that the facility failed to: 1) properly investigate an allegation of abuse, and 2) maintain documentation that an alleged violation of abuse was thoroughly investigated. This was found evident for 2 (Resident #113 and #110) of 9 residents reviewed for allegations of abuse. The findings include: 1. On 1/24/24 at 1:20 PM, the surveyor reviewed the facility's investigation into the alleged abuse allegation that occurred between Geriatric Nursing Assistant (GNA) Staff #31 and Resident #113. The investigation stated the allegation was reported to the facility weeks after the alleged incident happened. The investigation report stated that the facility, suspended the employee pending the investigation, assessed and interviewed other residents, notified police, and educated staff. However, there was no documentation to support this was completed Resident #113's skin assessment was in the file along with two staff statements stating Resident #113 was assessed with no concerns of abuse. On 1/24/24 at 1:23 PM, the surveyor interviewed…

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 interviews and record review, it was determined that the facility failed to follow the procedures to evaluate for safety and have a physician order for self-administration of medications. This was found evident in 1 (Resident #75) out of 1 resident reviewed for self-administration of medications. The finding include: On 1/17/24 at 7:58 AM, the surveyor reviewed Resident #75 ' s medical record. The review revealed that Resident #75 had a care plan written on 9/16/2021 that stated Resident #75 will self-administer eye drops as ordered per Resident's preference. Further review revealed no physician order written or medication self- administration assessment was completed after the care plan was written. On 1/25/24 at 10:19 AM, the surveyor conducted an interview with the Director of Nursing (DON). During the interview the DON described the process when a Resident requests to self-administer medications. The DON stated that an assessment must be completed to evaluate safety as well as obtain an order from the medical provider. The surveyor the asked the DON if Resident #75 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 record review, observation, and interview, it was determined that the facility failed to manage a resident's pain regimen following the physician ordered parameters. This was found to be evident for 1 (#102) out of 1 resident reviewed for administration of pain medication. The findings include: A pain scale is a way for you to measure your pain so that doctors can help plan how best to manage it. The pain scale helps providers keep track of how well the treatment plan is working to reduce pain and help to perform daily tasks. During a record review on 01/16/24 at 09:57 AM, the surveyor noted that Resident # 102 had an order written for Tramadol Tablet 50 milligrams, give one tablet by mouth, two times a day for moderate to severe pain. Review of the Medication Administration Record revealed that the resident had complained of a pain level of 4 once in January and the rest of the pain levels were documented as 0. All doses were documented as given. The facility Pain Management and Assessment Policy and Standard Procedures was reviewed on 01/22/24 at 12:37 PM. The 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 record review and staff interview, it was determined that the facility failed to have a process in place to ensure that the resident and the resident representative were provided a notice of transfer in writing and the Ombudsman was notified. This was evident for 3 (#3, #1, and #2) of 3 residents reviewed during the complaint survey. The findings include: 1) On 10/10/23 at 10:18 AM, a review of Resident #3's medical record revealed a progress note, dated 8/30/23, that documented the resident had been transferred to the hospital. Further review of the record revealed there was no transfer notice in the medical record. 2) On 10/11/23 at 9:30 AM during a medical record review for Resident #1, a nursing note dated 10/5/23 at 6:22 PM revealed the resident had been transferred to the hospital. A review of the electronic medical record and the hard chart revealed no notice of transfer. 3) On 10/10/23 at 8:45 AM, a medical record review for Resident #2 on 10/10/23 at 8:45 AM revealed a progress note, dated 5/9/23, that revealed the resident had been sent to the hospital due to 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.

Based on record review and staff interview, it was determined that the facility failed to have a process in place to ensure that the residents were oriented and prepared for a safe and orderly discharge. This was evident for 3 (#3, #1, and #2) of 3 residents reviewed during the complaint survey. The findings include: 1) On 10/10/23 at 10:18 AM, a medical record review for Resident #3 was conducted in response to complaint #MD00196311. The review revealed an attending physician visit note, dated 7/31/23, that documented the resident was legally blind and had schizophrenia. A nursing progress note, dated 8/30/23 at 1:48 AM, read that Resident #3 had an emergent need, the on-call physician was notified, and resident had been transferred to an acute care hospital. The nurse failed to document the resident had been oriented and what was done to prepare the resident for a safe and orderly discharge. On 10/10/23 at 10:53 AM, during an interview with Licensed Practical Nurse (LPN) Staff #2, s/he revealed they would discuss the transfer with a resident who was alert and oriented and document…

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, it was determined that the facility failed to have a process in place to ensure that the resident and resident representative were provided a copy of the bed hold policy within 24 hours of the time of transfer. This was 3 (#3, #1, and #2) of 3 residents reviewed during the complaint survey. The findings include: 1) On 10/10/23 at 10:18 AM, a review of Resident #3's medical record revealed a progress note, dated 8/30/23, that documented the resident had been transferred to the hospital. Further review of the record revealed there was no evidence that the bed-hold policy had been provided to the resident and or resident representative within 24 hours of the transfer. 2) On 10/11/23 at 9:30 AM, a medical record review for Resident #1 revealed a nursing note, dated 10/5/23 at 6:22 PM, that read the resident had been transferred to the hospital. Further review of the medical record failed to reveal evidence that the bed-hold policy had been provided to the resident and or the resident representative. 3) On 10/10/23 at 8:45 AM during a medical…

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 medical record review and interview with facility staff, it was determined that the facility failed to implement the off-hours on-call system for physicians when a resident status changed. This was evident for 1 of 3 residents (#10) when reviewed during a revisit survey. The findings include: Review of the medical record of Resident #10 at 9:30 AM on 12/12/23 revealed diagnosis including history of cardiovascular disease, hypertension, and paraplegia. Further review noted a hospital admission on [DATE]. A closer review of the nursing progress notes revealed that on 11/28/23 Resident #10 had a chest x-ray ordered to rule out pneumonia, secondary to a cough. The results, returned on the evening of 11/29/23 reported according to the nursing progress notes may reflect CHF (congestive heart failure), multifocal pneumonia or other conditions, findings new compared to 1/9/23. The note further documented that the findings were reported to PHP Telehealth twice but no answered yet, documented at 11/29/23 11:15…

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, it was determined that the facility had delegated duties to their staff that were outside their scope of practice. This was evident for 4 (Staff #1, #12, #11, and #10) of 4 License Practical Nurses. The findings include: The Annotated Code of Maryland Health Occupations Article, Title 8 is the Nurse Practice Act and contains the laws and regulations in which licensed nurses must follow and defines their scope of practice. Licensed nurses are governed by the Maryland Board of Nursing. According to the Nurse Practice Act Title 10 Maryland Department of Health Subtitle 27: Board of Nursing Chapter 10: Standards of Practice for Licensed Practical Nurses (LPN): .01 Definitions - B. (4) Case Management means a collaborative, process that assesses, plans, implements, coordinates, monitors, and evaluates options and services to meet the client's health needs through enhanced communication and use of available resources to promote quality client outcomes and cost effective care. B. (6). a. Comprehensive nursing assessment means an assessment…

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

Based on the medical record and staff interviews, the facility staff failed to provide a Care Plan for Resident #25's continuing care, to the hospital where the resident was being sent. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process. The findings include: On 4/17/19 around 9:55 AM while reviewing Resident #25's medical record for a recent hospitalization, it was noted that on 3/7/10 the resident was noted to have a large amount of active bleeding from the rectum. The doctor ordered the facility to transfer the resident to the emergency room (ER) for a possible gastrointestinal bleed. Review of the hospital transfer record and the resident's chart did not reveal that the below required information was sent to the hospital during the transfer. 1. A copy of Resident #25's Care Plan. This information was discussed with the Director of Nursing (DON) who acknowledged the omission.

Based on the medical record and staff interview, it was determined that the facility staff failed to provide written notification to the appropriate parties, of Resident #25's transfer out to the hospital. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process. The findings include: On 4/17/19 around 9:55 AM while reviewing Resident #25's medical record for a recent hospitalization, it was noted that on 3/7/10 the resident was noted to have a large amount of active bleeding from the rectum. The doctor ordered the facility to transfer the resident to the emergency room (ER) for a possible gastrointestinal bleed. Review of the hospital transfer record and the resident's chart did not reveal that the facility provided written documentation to the rtesident, or the resident's representative of the reason for the transfer. In addition, the facility did not notify the Ombudsman of the transfer, as well. This information was given to the Director of Nursing (DON), who acknowledged it.

Based on the medical record and staff interview, it was determined that the facility staff failed to provide required written notice for Resident #25, or the resident's Responsible Party (RP), of the bed hold policy during a transfer out of the facility. This was evident for 1 out of 2 residents investigated for hospitalization during the survey process. The findings include: On 4/17/19 around 9:55 AM while reviewing Resident #25's medical record for a recent hospitalization, it was noted that on 3/7/10 the resident was noted to have a large amount of active bleeding from the rectum. The doctor ordered the facility to transfer the resident to the emergency room (ER) for a possible gastrointestinal bleed. Review of the hospital transfer information in the resident's chart did not reveal that a bed hold policy was given to the resident prior to leaving the building. This policy educates the resident on whether a bed can be held during the resident's absence, and or if not, the possibility of having to privately pay to hold the resident's bed, until the resident's return.

Based on observation and staff interview it was determined the facility failed to ensure the narcotic count for one narcotic prescribed for Resident #204 and one narcotic prescribed for Resident #123 was accurately documented. This was evident for 2 of 12 narcotics reviewed for reconciliation during the survey. The findings include: When the number of narcotics documented as available for administration is compared to the actual number of narcotics on hand, the process is called narcotic reconciliation. This process is used to help identify any discrepancies between the number of narcotics purchased and the number of narcotics actually given to residents and helps determine if any narcotics are missing. On 4/16/19 beginning at 9:55 AM, an inspection of medication storage was initiated on the first floor. Resident #204 was found to have 26 tablets of Tramadol 50 milligrams (mg). However, it was documented in the narcotic book that there were supposed to be 28 tablets. Unit Manager #2 was present and confirmed the finding. On 4/17/19 beginning at 8:43 A.M. an inspection of medication…

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 it was determined that the facility staff failed to use appropriate infection control procedures while handling food for Resident #72. This was evident for 1 out of 38 residents observed during the survey process. The findings include: On 4/12/19 around 8:00 AM during observation of the morning medication pass, writer witnessed staff #1, assisting Resident #72 with breakfast set up. Writer witnessed staff #1 pick-up Resident #72's bread from the tray with bare hands. While holding the bread staff #1 began spreading the condiment on the resident's bread. Foods that are not being cooked again should not be handled with bare hands. It is the facility's responsibility to protect its residents from any possible contaminations.