Germantown Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based review of facility documentation, facility policy, clinical records, and interviews with staff, it was determined that the facility failed to ensure that a resident's care plan was revised timely to address ongoing and escalating aggressive behaviors for one of two sampled residents. (Resident R1) Findings include: Review of facility's policy, titled Resident Centered Care Plans revised January 2011, establishes that care plans are person-centered, interdisciplinary, and written in language that is understandable to all involved. The purpose of the care plan is to provide a resident-specific, timely, and comprehensive plan of care that addresses each resident's needs, conditions, impairments, and strengths. Care plans are developed promptly and include measurable goals, specific interventions, and time frames. Importantly, care plans must be updated whenever there are changes in the resident's condition, status, or treatment needs, not only during quarterly reviews. While the interdisciplinary team…

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, review of clinical records, review of facility policy, and interview with staff, it was determined that the facility did not develop and implement a comprehensive, resident-centered care plan for seven of 35 residents reviewed related to wounds and Enhanced Barrier Precaution's. (Resident R36, R71, R114, R156, R24, R187, and R41)Findings include:Review of facility policy Resident Centered Care Planning, revised on 06/06, indicates that purpose of policy is to utilize the Resident Assessment Process (RAP) according to Federal Regulations; further indicating that RAP is to be completed by Nursing staff for pressure ulcers.Review of Resident R36's clinical record revealed the resident was assessed with Stage IV (ulcer involving loss of skin layers, exposing muscle) pressure ulcer on coccyx.Review of R36's care plan revealed no evidence of goals or interventions related to Enhanced Barrier Precautions (EBP).Review of Resident R71's clinical record revealed the resident was assessed with Stage…

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, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to ensure that urinary catheter bag were properly position to prevent contact with the floor for one of one residents review with an indwelling urinary catheter. (Resident Review of facility policy titled Urinary Catheter Care, last reviewed on June 20, 2019, revealed the purpose of the policy is to reduce the risk of the indwelling urinary catheter becoming the source of infection and to reduce the transmission of infection to or between residents/ participants with indwelling urinary catheters. Furthermore, Drainage Bags should never touch the floor. Review of Resident R63's clinical record revealed that resident was admitted to the facility on [DATE] with the diagnoses of End stage renal disease (Kidney failure), Aphasia (disorder that affects a person's ability to communicate). Review of Resident R63's physician order date March 20, 2024, revealed Change suprapubic catheter…

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

Based on review of clinical records, review of policies, and interview with staff, it was determined that facility did not ensure to provide and/or document the provision of pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the influenza for 51 of 54 residents reviewed (Resident R41, R26, R28, R29, R30, R34, R42, R3, R43, R50, R12, R64, R65, R73, R75, R86, R97, R114, R117, R119, R120, R132, R136, R140, R141, R143, R11, R146, R151, R154, R171, R8, R178, R18, R24, R77, R107, R130, R139, R1, R152, R162, R173, R175, R21, R22, R25, R10, R27, R32, R35) Findings include: Review of facility policy 'Influenza vaccine - protocol for residents,' reviewed January 14, 2025, indicates that the immunization records of all residents in the facility will be reviewed annually. All residents will be offered the influenza vaccination unless there is a documented contraindication. Residents/Responsible Representative will be offered a copy of the current year Vaccination Information Statement (VIS)…

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 clinical records, review of policies, and interview with staff, it was determined that facility did not ensure to provide and/or document the provision of pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for seven of seven residents reviewed (Residents R120, R24, R141, R43, R145, R156, R83) Findings include:Review of facility policy 'Covid Vaccine protocol for staff and residents,' reviewed January 14, 2025, indicates that education will be provided for decline referencing CDC guideline.Interview with facility's infection preventionist, employee E6, on Wednesday, July 30, 2025, at 10:00 am, revealed that education on risks vs benefits for covid-19 immunizations is not completed unless a resident declines the vaccine.Review of facility provided documentation revealed Resident R120, received covid-19 immunization on March 25, 2025; review of R120's clinical record revealed no evidence of education provided. Review of facility provided…

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 clinical record review revealed that the facility failed to ensure that a rational was documented related to pharmacy recommendations for one of 35 residents reviewed. (Resident R2)Findings include:Review of facility policy titled Pharmacy Consultation Recommendations revised on October 1, 2018, revealed The Pharmacy Consultant will review all resident charts monthly and as needed to assess the resident's medication regimen, associated orders to assure proper medication selection, and potential risks associated with pharmacological interventions and to suggest therapeutic changes. Under Procedure, policy states The Unit Manager/ RN supervisor will document the Physician/CRNP's (Certified Registered Nurse Practitioner) response as a verbal order if the Physician/ CRNP has accepted the recommendation, or as a narrative in the progress notes if the Physician/ CRNP has declined the recommendation including the Physician/ CRNP's reason for not accepting the recommendation. Review of Resident R2's clinical…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility documentation and interview with staff, it was determined the facility failed to provide timely notice on non-medical coverage (NOMNC) for one of three residents reviewed. (Resident 117) Findings Include: Review of Resident R117's clinical records shows the resident was re-admitted to the facility on [DATE]. Resident R117 remained at the facility after his last day of coverage was September 2, 2024. Review of the social service note from September 18, 2024 revealed Note Text: Resident Representative, notified on September 18, 2024 of resident's last coverage date of September 3, 2024. Resident Representative informed of right to appeal last coverage date. Resident Representative stated they would like resident to continue working with therapy. Social Services informed Resident Representative that resident will be picked up by rehab on Physical Therapy caseload per rehab Director. Social Services will provide Resident Representative copies of Notice of Medicare Non-Coverage and Advance…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, and interview with staff and residents, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to use of a urinary catheter and discharge status for two of 38 records reviewed (Residents R50 and R178). Findings include: Observations of Resident R50 conducted on September 17, 2024, at 11:30 a.m. confirmed that the resident had no urinary catheter present. Interview with the resident at this time revealed that the catheter had been in use because of my wound on my backside but that it had been discontinued due to the progress of the wound healing. Review of clinical documentation for Resident R50 revealed that she was admitted to the facility on [DATE], and had diagnoses of pressure ulcer of the sacral region, stage 4 (stage 4 pressure ulcers extend through the skin and fat layers into the muscle, and may extend to the bone), and muscle weakness. Also revealed was a physician order to discontinue 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 review of facility policy, observation, clinical record review, and interview with staff and residents, it was determined that the facility did not develop a comprehensive care plan related oxygen use for one of 35 records reviewed (Resident R167). Findings include: Review of Resident Centered Care Planning policy revised 2023, revealed that based on a comprehensive, interdisciplinary assessment, the care team will address individualized resident needs to include physical, psychosocial, functional, recreational, spiritual, educational and communication needs. Review of clinical documentation for Resident R167 revealed that she was admitted to the facility on [DATE], and had diagnoses of asthma and obstructive sleep apnea. A physician's order was obtained on January 29, 2024, which stated O2 (oxygen) at 2LPM (liters per minute) via nasal cannula at bedtime for hypoxia (low blood oxygen levels). Review of the resident's care plan revealed that no care plan had been developed for the resident use 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 review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not revise and update the resident's plan of care related to urinary catheter use for one of 35 records reviewed (Resident R50). Findings include: Review of Resident Centered Care Planning policy revised 2023, revealed that based on a comprehensive, interdisciplinary assessment, the care team will address individualized resident needs to include physical, psychosocial, functional, recreational, spiritual, educational and communication needs. Observations of Resident R50 conducted on September 17, 2024, at 11:30 a.m. confirmed that the resident had no urinary catheter present. Interview with the resident at this time revealed that the catheter had been in use because of my wound on my backside, but that it had been discontinued due to the progress of the wound healing. Review of clinical documentation for Resident R50 revealed that she was admitted to 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that services were provided to maintain hearing and vision for two of 35 records reviewed (Residents R53 and R142). Findings include: Review of Guidelines for Use of the Consult Tracking Log policy reviewed April 2022, revealed that a physician's order for a consult is entered in the electronic record as needed. A progress note should be written in PCC for the reason of consult by the nurses. Unit Clerk will review the order in PCC and schedule the appointment, notify the resident representative with the date and time, schedule the escort if needed, and transportation. Unit clerk or designee will write a note under consultation confirming the appointment, responsible party notification and transportation notification. In an interview with Resident R142 on September 17, 2024, at 1:45 p.m., the resident stated that they had checked her hearing a while…

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 staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E9). Findings include: An interview on September 17, 2024, at 10:30 a.m. with Employee E4, Food Service Director (FSD), revealed that his responsibilities included oversight of ordering, receiving, storing, preparation and service of food. Further interview with the FSD confirmed that he was not currently a certified dietary manager (CDM); or a certified food manager (CFM); or had a national certification for food service management and safety from a national certifying body; or had an associate's or higher degree in food service management or hospitality from an accredited institution; and that she had not received frequently scheduled consultations from a qualified dietitian. A review of Employee E4's credentials revealed that Employee E4 did not meet the statutory qualifications of a director of food and nutrition services. During an interview on September 19, 2024, at 11:30 a.m. with the Administrator,…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, clinical record review and interview with staff, it was determined that facility failed provide resident with pressure injury measures to prevent the development or worsening of pressure injury for one resident. (Resident R1) Findings include: Review of facility policy on wound prevention and maintenance guidelines revealed that under section Policy: It is the policy for this facility that all residents are assessed for skin risk, using the Braden Scale, and that residents at risk, including those with pressure injury, will have appropriate plans of care implemented. Under section Purpose: To provide at-risk residents with pressure reducing or relieving surfaces and devices to reduce the mechanical forces of pressure, shear, friction and/or moisture, which contribute to tissue breakdown. Under section Procedure: #4. Based on the assessment and Braden Scale, a licensed nurse will initiate treatment with appropriate pressure redistribution and devices. #8. Products vary greatly…

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.