Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bridgepoint Subacute And Rehab Capitol Hill during CMS and state inspections, most recent first.
Failure to Order Wound Consult and Treatment for New Buttock Blister: An RN observed an open blister on a resident’s right buttock during incontinent care and documented that the MD was notified and a wound consult and Xeroform treatment were obtained, but the orders were not found in the chart. Staff did not document use of the facility’s skin assessment tool or follow the pressure ulcer/injury policy, and within days the blister was documented as a Stage 3 pressure injury.
Incomplete investigation of missing controlled medication: Facility staff did not complete a thorough investigation of a missing Tramadol bubble pack belonging to a resident with a PEG tube, Stage 4 pressure ulcer, anoxic brain damage, epilepsy, and muscle weakness. The FRI and final report noted the nurse involved was interviewed, but there was no documented evidence that the nurse was off duty during the investigation period or that staff investigated inconsistencies between the controlled drug record and the physician’s order.
Care Plan Not Updated for New Skin Abrasions: A resident with a stage 3 sacral PI, surgical wound, and high Braden risk developed new right knee and left medial lower leg abrasions, but the care plan was not revised to include goals and interventions for those new skin issues. The record showed the abrasions were later noted as slowly improving, and the DON acknowledged that the care plan had not been updated.
A resident with cerebral infarction, muscle weakness, and Stage 3 and Stage 4 pressure ulcers was found with wet, stained gown and linens and dry stool on his thigh, while staff gave conflicting accounts of when care was last provided. The resident’s daughter said she often found him needing care, and a CNA said he was not repositioned when first seen in the morning and was only turned after ADL care began later, despite a care plan calling for repositioning at least every 2 hours.
A resident with a tracheostomy, chronic respiratory failure, aphasia, and severe ADL dependence was sent to a podiatry appointment without a nurse or trach supplies. Records, family report, and staff interview showed the resident traveled with transportation only, while the podiatry office was not notified and was unprepared to manage suctioning needs if needed.
A CNA provided wound care outside his scope for a resident with cerebral infarction, muscle weakness, and stage 3/4 pressure ulcers. The CNA reportedly used the same gloves to clean fecal matter and remove a soiled sacral dressing, then pulled on stuck packing without moistening it, sprayed wound cleanser on it, and caused bleeding. Staff stated wound care was not within CNA scope, and the complainant reported the CNA had changed the sacral dressing on multiple occasions.
Improper Storage of Open Ozempic Pen: Staff failed to ensure proper storage of a resident's Ozempic multi-use pen. Surveyors found an opened pen in the med refrigerator that had been kept beyond the manufacturer's 56-day use period, and an LPN acknowledged she was unsure how long the pen could be used after opening.
Surveyors identified that staff failed to prevent accident hazards by allowing portable space heaters in resident rooms and not providing adequate supervision or safety measures for residents who smoked, including those with significant medical and cognitive impairments. Staff were often unaware of which residents smoked or the facility's smoking policy, and residents were found with smoking materials and without required safety equipment or care plans.
A resident who was totally dependent on staff and at risk for pressure ulcers developed a Stage 3 pressure injury on the left foot that went unidentified and undocumented for an extended period, despite regular documentation of skin assessments and preventive interventions. The wound was only discovered at an advanced stage, and staff interviews confirmed the lack of earlier documentation or recognition of the skin breakdown.
Staff were not consistently educated on resident rights and facility responsibilities due to incomplete documentation and lack of evidence that all employees received required training. Leadership interviews confirmed gaps in the education process, with some training provided only as needed and insufficient records to verify content or participation.
Facility staff did not receive documented training on the elements and goals of the QAPI program. Review of education records revealed only a list of training topics and sign-in sheets, with no evidence that QAPI training materials or reviews were provided. Leadership confirmed that required QAPI training could not be substantiated, and some staff did not receive the training at all.
Facility staff did not provide or document a comprehensive training program to effectively communicate compliance and ethics standards, policies, and procedures to all staff. Training records only showed a list of topics and sign-in sheets for a skills fair, with no evidence that all staff received the required education, especially those not present at the event. Leadership interviews confirmed gaps in the training process and documentation.
The facility failed to provide documented evidence of required in-service training for CNAs, with records showing only three months of training and missing staff sign-in sheets. Leadership confirmed that comprehensive documentation was lacking, and some training was only provided as needed or remotely by a newly hired educator.
Surveyors found that the facility did not have documented evidence of an effective behavioral health training program for all staff. Review of training records and interviews with facility leadership confirmed that behavioral health care and services training was not included in the annual skills fair and had not been consistently provided, with recent training only occurring remotely.
Facility staff did not document that information about the right to formulate or refuse an advance directive was provided to several residents or their representatives, despite care plans referencing end-of-life wishes and the facility's policy requiring such documentation. The process relied on leaving forms in resident rooms without follow-up, resulting in missing evidence that residents or their RPs received the necessary information.
Multiple residents with complex medical conditions did not have individualized care plans addressing their specific needs, such as central IV line care, use of an immobilization boot, language interpretation preferences, indwelling catheter management, and dietary modifications. Despite physician orders and documented needs, staff failed to create or implement care plans with measurable goals and interventions, as confirmed by record reviews, staff interviews, and observations.
A resident with multiple diagnoses and moderate cognitive impairment was allowed to self-administer an Albuterol inhaler without an IDT assessment to determine clinical appropriateness or safety. The inhaler was kept at the bedside, and there was no documentation in the MAR regarding its use, with staff unable to specify who was responsible for recording administration.
A resident with multiple medical conditions was allegedly subjected to verbal abuse by a CNA, as reported by the resident's daughter. The facility failed to maintain documentation of the incident or the investigation, and staff interviews confirmed that the CNA was suspended and later reassigned, but no records of the investigation could be found.
A non-ambulatory, cognitively impaired resident who required extensive assistance with bed mobility and transfers was found with all four bedrails raised on two occasions, without proper documentation or justification in the medical record. Although a physician's order allowed for one-quarter side rails as an enabler, there was no evidence supporting the use of all four bedrails, and facility staff acknowledged the lack of a bedrail policy and appropriate documentation.
Staff failed to promptly report two separate incidents of alleged staff-to-resident verbal abuse, as required by facility policy and state regulations. In both cases, CNAs witnessed or were involved in verbal abuse toward residents with cognitive impairments but did not immediately report the incidents to the administrator or appropriate authorities. The events only came to light during investigations into other abuse allegations, and staff interviews confirmed delays in reporting due to lack of awareness, fear of retaliation, and concerns about confidentiality.
Facility staff did not complete thorough investigations into two incidents: one involving a resident's missing cellphone and another involving an allegation of staff-to-resident verbal abuse. In the first case, not all staff present during the incident were interviewed. In the second, the final report omitted new CNA statements alleging additional verbal abuse by the same staff member toward other residents, despite these statements being received before the report was finalized.
Facility staff did not review or update the comprehensive care plan for a resident with complex medical needs after multiple MDS assessments, as confirmed by record review and staff interview.
Facility staff did not ensure two residents who were unable to perform ADLs independently received needed grooming and hygiene care. One resident was observed with long, dirty fingernails despite requesting assistance, and an LPN acknowledged the issue but did not address it. Another resident, fully dependent on staff and with a podiatry consult ordered, had long toenails that were not addressed over several weeks, with no evidence the consult process was followed or the podiatrist notified.
Staff failed to follow professional standards and physician orders in two cases: a nurse prepared a Heparin injection using an IM needle instead of the required SQ needle for a resident with DVT, and staff did not turn and reposition a dependent resident every two hours as ordered, leaving the resident in the same position for three hours despite documentation and care plan requirements.
A resident with severe cognitive impairment and dependent on tube feeding did not receive water flushes via PEG tube as ordered, due to the feeding pump being set to deliver flushes every six hours instead of every four hours. An LPN acknowledged the error and stated that the settings were not checked at the start of the shift.
Facility staff did not ensure timely and appropriate care for central IV lines for two residents, resulting in one resident's dressing not being changed within the required seven-day interval and another resident's dressing lacking a date label. These actions were inconsistent with professional standards and facility policy.
A resident with multiple complex diagnoses did not have their medication regimen reviews addressed by a physician for four months, despite repeated pharmacist recommendations for clarification on PRN opioid parameters and antipsychotic indications. The attending physician did not document review or action on these recommendations, resulting in a lapse in required oversight of the resident's care.
Staff failed to demonstrate appropriate competencies in two cases: a CNA attempted to restart a gastrostomy tube feeding machine without notifying a nurse, despite not being trained for this task, and an RN did not complete a full assessment or document all vital signs during a resident's change in condition before contacting the provider and arranging hospital transfer.
A resident with complex medical needs did not receive their ordered Levetiracetam solution because staff could not locate the medication, despite records showing it had been delivered. An RN attempted to use another resident's medication, which was stopped by a surveyor. The facility's policy for medication receipt and storage was not followed, resulting in the medication not being available for administration.
A resident with multiple complex conditions did not have pharmacist-identified medication regimen irregularities reviewed or acted upon by the attending physician for four consecutive months. Despite repeated pharmacy recommendations regarding pain medication parameters and antipsychotic indications, there was no documented physician response until several months later, in violation of facility policy.
Staff did not maintain the medication error rate at or below 5%, with observations revealing four errors out of 25 opportunities, resulting in a 16% error rate. Staff interviews confirmed that education on medication administration is provided.
Surveyors found multiple instances where opened and expired insulin vials and pens were stored in medication refrigerators, some undated and some belonging to discharged residents. Staff administered expired insulin to a resident and failed to remove unused medications in a timely manner, with nursing staff acknowledging lapses in checking and discarding expired or undated medications as required by manufacturer guidelines.
A resident with dysphagia and multiple medical conditions, who required a soft and bite-sized pleasure diet, was served roast beef that was not mechanically altered to the prescribed texture. Staff involved were unable to confirm the appropriateness of the meal, and it was later acknowledged by the dietary director that a regular diet was mistakenly provided instead of the required bite-sized diet.
Surveyors identified multiple sanitation and equipment maintenance deficiencies, including improper food storage, soiled fixtures, expired nutritional supplements, missing light guards, and inoperative kitchen equipment. These issues were acknowledged by staff during the inspection.
On several sampled days, the facility did not provide the required minimum average of 4.1 hours of direct nursing care per resident per day, nor the mandated 0.6 hours by an RN, due to staff shortages and lack of awareness of staffing requirements by the staffing coordinator.
Staff documented the administration of medications, treatments, and vital signs for a resident who had already been transferred to the hospital due to chronic respiratory failure and related conditions. This resulted in inaccurate medical records, as confirmed by staff interviews and record review.
Staff failed to consistently follow infection control and enhanced barrier precaution protocols, including not performing hand hygiene after glove removal, and not wearing gowns during high-contact care activities for residents with complex medical needs. Staff acknowledged these lapses when questioned.
Staff did not ensure the environment remained free of pests, as evidenced by the presence of mouse traps and droppings in food preparation and dishwashing areas, as well as flying insects in the kitchen. These issues were confirmed by a facility employee during an interview.
Facility staff failed to document background checks and abuse education for an RN involved in an incident with a resident. Additionally, staff did not remove a CNA accused of verbal abuse from the facility during the investigation, violating policies designed to protect residents.
The facility failed to provide written information on the duration of the State Agency's bed-hold policy before transferring three residents to the hospital. The deficiencies involved residents with varying cognitive statuses and occurred due to delays and omissions in completing the required forms.
Facility staff failed to develop a comprehensive care plan for a resident with severe cognitive impairment and an indwelling urinary catheter. Despite a physician's order for catheter care every shift, the care plan lacked documented goals and approaches. The deficiency was confirmed by the DON during an interview.
A resident's suprapubic catheter was dislodged during care by a CNA, resulting in small bleeding at the stoma site. The resident, who had multiple diagnoses including Functional Quadriplegia and Neurogenic Bladder, had a care plan to prevent catheter-related trauma. The Director of Nursing confirmed improper handling of the catheter and re-inserviced the CNA involved.
An LPN failed to ensure effective pain management for a resident with chronic pain, as there was no documented evidence of pain medication administration despite high pain levels reported on two separate dates. The LPN could not explain the lack of documentation, indicating a lapse in following the prescribed pain management protocol.
An LPN pre-poured and pre-crushed medications for five residents, contrary to guidelines and facility protocols, compromising resident safety. The Unit Manager confirmed that medications should be administered as ordered and not pre-prepared.
Facility staff failed to follow the system for reconciling controlled medications, leaving multiple entries on the January 2024 Controlled Medication Shift Change Log blank. An LPN admitted to forgetting to document the count, and the DON confirmed the process was not followed.
The facility failed to serve cold food at or below 41 degrees Fahrenheit on two occasions. A test tray revealed pineapples at 51 degrees Fahrenheit and pears at 53 degrees Fahrenheit. The Chef acknowledged the findings, and the Food Service Director stated that cooling bowls with lids would be ordered.
Facility staff failed to maintain an administrative record for an agency RN who worked at the facility for nearly two years, violating state regulations. The deficiency was discovered during an investigation of an incident where a resident reported being screamed at by the RN.
Failure to Order Wound Consult and Treatment for New Buttock Blister
Penalty
Summary
Facility staff failed to order a wound consult and treatment for a resident who was observed with an open blister on the right buttock, and the area later progressed to a Stage 3 pressure ulcer. The resident had diagnoses including a pre-existing Stage 4 sacral pressure ulcer, type 2 diabetes mellitus, metabolic encephalopathy, generalized muscle weakness, and need for gastrostomy care. Physician orders included inspecting the skin of all admissions, evaluating and treating any wound that developed during the stay, and turning and repositioning every 2 hours. On 02/04/26, an RN documented during incontinent care that she noticed an open blister on the right gluteal area, cleansed the wound, applied Xeroform dressing, and obtained a wound consult, with the physician reportedly responding with the same instructions. However, review of the physician orders, MAR, and TAR for February 2026 showed no documented evidence that the Xeroform treatment or wound consult were actually ordered. Review of progress notes from 02/04/26 through 02/09/26 also showed no documented evidence that staff used the facility's pressure ulcer/injury assessment tool or followed the policy steps for assessing and documenting the skin alteration. A wound assessment on 02/09/26 documented the right buttock wound as a Stage 3 pressure ulcer, acquired in house, measuring 2.30 cm by 1.00 cm by 0.30 cm. The wound care nurse practitioner later stated that the resident was being seen weekly for multiple pressure injuries, including the sacral wound present on admission, a facility-acquired right buttock wound that started as a Stage 3, and a left heel Stage 2 injury. He stated he was not made aware of the right buttock blister before 02/09/26 and that a blister could progress to a Stage 3 or Stage 4 pressure ulcer within 5 days in a resident with fragile skin, moisture, lack of proper treatment, and shearing.
Incomplete investigation of missing controlled medication
Penalty
Summary
Facility staff failed to complete a thorough investigation of a facility-reported incident involving the missing Tramadol HCl oral tablet 50 mg bubble pack belonging to Resident #38. Resident #38 was admitted with diagnoses including Stage 4 pressure ulcer of the sacral region, anoxic brain damage, epilepsy, and muscle weakness, and had a physician’s order for Tramadol 50 mg via PEG tube every 8 hours for moderate to severe pain. The resident’s MARs for August and September 2025 showed the medication was documented as administered at 2:00 AM, 10:00 AM, and 6:00 PM from 08/21/25 through 09/09/25. The facility’s initial FRI stated that the Tramadol bubble pack was missing and that the investigation was ongoing, and the final report later stated that the nurse involved was interviewed and could not explain the missing narcotics. However, review of the investigation documents showed no documented evidence that Employee #30 did not work at the facility during the investigation period, and no documented evidence that staff investigated why the times and dosages on the Controlled Drug Receipt/Record Disposition Form were inconsistent with the physician’s order. The DON acknowledged the findings during interview.
Care Plan Not Updated for New Skin Abrasions
Penalty
Summary
Facility staff failed to revise and update Resident #112’s care plan after she developed new right knee and left medial lower leg abrasions. The resident was admitted with multiple diagnoses including pressure ulcer of the sacral region, encephalopathy, chronic respiratory failure with hypoxia, and iron deficiency anemia. On admission, she was documented as high risk for pressure injury with a Braden Scale score of 11, and her record also showed a stage 3 sacral pressure injury and a midline abdominal surgical wound present on admission. Care plan focus areas were initiated for the sacral pressure ulcer and the abdominal wound, but no updated care plan focus area was documented for the new abrasions identified later. The medical record showed that the right knee and left medial lower leg abrasions were first documented as new skin findings, and later notes described them as slowly improving in epithelium. Despite these new wounds and ongoing skin changes, the care plan was not updated to include goals and interventions for the abrasions. During interview, the DON reviewed the care plan and acknowledged the findings, stating that updating the care plan was up to the unit managers, supervisors, and the interdisciplinary team.
Incontinent Care and Repositioning Not Provided Timely
Penalty
Summary
Resident 43, who had a history of cerebral infarction, muscle weakness, and Stage 3 and Stage 4 pressure ulcers, was found lying in bed with light red wet spots on his gown and bed linen and dry, brown stool on his left thigh. The resident was dependent on staff for activities of daily living, always incontinent of bowel, had a urinary catheter, and had one Stage 3 and one Stage 4 pressure wound. During the observation, the resident’s daughter stated she often found her father needing care. An assigned RN stated the wetness and staining may have been caused by spilled medication, while an assigned CNA stated he had made rounds at 7:00 AM and the bed was clean at that time, then said he was there to provide care. The resident also had a care plan directing assistance with turning and repositioning at least every 2 hours or more often as needed because of pressure ulcers related to chronic respiratory failure, chronic kidney disease, diabetes, and immobility. The daughter reported that staff did not turn and reposition her father for hours and that she sometimes turned him herself if staff had not done so within 3 hours. Multiple observations showed the resident lying supine at 4:50 AM, 8:50 AM, 9:55 AM, and 10:20 AM, and an assigned night-shift CNA stated he had just completed care, including a bed bath. An assigned dayshift CNA stated he first observed the resident around 7:00 AM but did not reposition him, and that he repositioned the resident only after providing ADL care beginning around 10:30 AM.
Resident With Tracheostomy Sent to Appointment Without Nursing Accompaniment
Penalty
Summary
The facility failed to ensure that a resident with a tracheostomy was accompanied by nursing staff during a podiatry appointment. Resident #43 was admitted with diagnoses including aphasia, chronic respiratory failure, tracheostomy, and muscle weakness. A physician order directed trach collar oxygen at 28% and trach and suction care by a respiratory therapist and a nurse every shift. The quarterly MDS coded the resident as requiring maximum staff assistance with all ADLs, tracheostomy care, suctioning, and respiratory services. A nursing note documented that the resident went to the podiatry appointment and returned by transportation. A complaint submitted to the State Agency stated that the resident was transported without accompanying supervision or support from facility staff, and that the podiatry office was not prepared to manage a potential airway emergency because there was no prior notification or suction equipment available. During interview, the unit manager stated the resident was sent without a nurse or tracheotomy supplies and that this was an oversight because staff thought the transportation company would provide supervision during the appointment. The complainant also reported that the podiatry office called to express concern that the resident had been sent without facility staff or tracheostomy supplies.
CNA Performed Wound Care Outside Scope and Used Improper Dressing Removal Technique
Penalty
Summary
The facility failed to ensure that Employee #22, a CNA, stayed within scope of practice and used proper wound care technique for Resident #43, who had a history of cerebral infarction, muscle weakness, chronic respiratory failure, chronic kidney disease, diabetes, and stage 3 and stage 4 pressure ulcers. The resident’s care plan directed staff to administer ordered treatments and monitor effectiveness, and a physician order required the sacral wound to be cleansed, packed with collagen and hydrogel-moistened rolled gauze, and covered with a bordered dressing daily and as needed. A wound assessment documented a stage 4 sacral wound measuring 4.00 cm by 6.00 cm by 2.90 cm. A complaint alleged that during personal care, the CNA used the same gloves to clean fecal matter and then remove the resident’s old wound dressing, attempted to pull out stuck packing without moistening it, sprayed wound-cleaning solution on the dressing, and immediately pulled again, causing the resident’s skin to bleed. During interviews, staff stated that wound care was not within the CNA’s scope of practice and that the CNA should only notify the nurse if a wound was soiled or came off during bathing. The complainant and the DON reported that the CNA had changed the sacral dressing on several occasions, removed a stool-soiled dressing, cleaned the area, replaced it with clean gauze, and secured it with tape.
Improper Storage of Open Ozempic Pen
Penalty
Summary
Facility staff failed to ensure proper storage of Resident #43's medication, Ozempic (semaglutide) multi-use pens. The resident was admitted with diagnoses including morbid obesity and COPD, and had a physician's order dated 10/29/25 for Ozempic 2 mg subcutaneously every Wednesday for 90 days. During observation of the medication storage refrigerator on 04/22/26 at 10:20 AM, surveyors found an open box of Ozempic pens for Resident #43 with handwritten notation indicating it was opened on 11/02/25. According to the manufacturer, an Ozempic pen may be stored for 56 days after first use, and the evidence showed the resident's pen had been kept beyond that recommended period and should have been discarded on 02/11/26. In interview, Employee #33 acknowledged the finding and stated she was unsure how long an Ozempic pen can be used after opening.
Unsafe Resident Environments Due to Space Heaters and Inadequate Smoking Supervision
Penalty
Summary
Facility staff failed to ensure that resident environments were free from accident hazards and did not provide adequate supervision to prevent accidents. Multiple deficiencies were identified, including the presence of portable space heaters in resident rooms and inadequate supervision and unsafe smoking practices among residents identified as smokers. Four portable space heaters were observed in use in the rooms of non-ambulatory residents, despite a facility policy prohibiting such appliances in resident care areas. Staff interviews revealed a lack of awareness regarding the prohibition of space heaters, and the heaters were found plugged in and operating near residents' beds. In addition to the space heater issue, the facility did not adequately supervise or implement safe smoking practices for several residents with significant medical conditions, such as chronic respiratory failure, muscle weakness, paraplegia, and cognitive impairments. Some residents were found to possess cigarettes and lighters, and were smoking outside the building without staff supervision or proper safety equipment, such as smoking aprons. There was a lack of individualized care plans addressing smoking for these residents, and staff were often unaware of which residents smoked or the facility's smoking policy. In some cases, residents with impaired mobility or cognitive status were allowed to keep smoking materials on their person or in their rooms, and staff did not monitor for behaviors such as receiving cigarettes from other residents. Observations and interviews indicated that staff did not consistently provide or document education on the smoking policy to residents or staff, and there was confusion among staff regarding the facility's status as a non-smoking facility. Some residents reported not being informed about the smoking policy or not receiving required adaptive equipment for safe smoking. The lack of supervision and failure to implement safety measures for both space heaters and smoking practices resulted in the identification of Immediate Jeopardy situations by surveyors.
Failure to Identify and Document Pressure Ulcer Led to Advanced Wound
Penalty
Summary
Facility staff failed to consistently assess and document changes in the skin condition of a resident who was totally dependent on staff for all activities of daily living due to quadriplegia and other significant medical conditions. The resident was identified as being at risk for pressure ulcers and had care plans and physician orders in place for regular skin assessments, use of pressure-reducing devices, and frequent repositioning. Despite these interventions, there was no documented evidence of any skin integrity issues with the resident's left foot in the progress notes or treatment administration records for an extended period. The deficiency was identified when a licensed practical nurse discovered a wound on the resident's left foot, which was subsequently assessed by a wound care nurse practitioner and determined to be a Stage 3 pressure injury. The wound was described as having significant tissue involvement, with exposed subcutaneous tissue and moderate serosanguineous exudate. Interviews with staff confirmed that regular head-to-toe skin assessments were documented as completed, but the pressure ulcer was not identified until it had progressed to an advanced stage. Further investigation revealed that the resident's left foot had been pressing against the bed's footboard, likely contributing to the development of the pressure injury. The lack of timely identification and documentation of the skin breakdown, despite ongoing documentation of completed assessments and interventions, resulted in actual harm to the resident.
Deficiency in Staff Education on Resident Rights and Facility Responsibilities
Penalty
Summary
Facility staff failed to ensure that all employees were adequately educated on resident rights and the facility's responsibilities as required by federal regulations. Record reviews showed that while the facility's assessment and policies indicated that staff training on resident rights was to occur during orientation and through quarterly in-service programs, there was insufficient documentation to confirm that this training was consistently provided. Specifically, the education and training binder only contained a list of training topics and sign-in sheets from a skills fair, without evidence of the actual content delivered or proof that all staff, including those absent from the skills fair, received the required training. Interviews with facility leadership confirmed the lack of substantiating documentation regarding the specific information provided to staff on resident rights. The Regional Director of Operation and the Administrator both acknowledged gaps in the education process, with the Administrator noting that some training was provided on an as-needed basis and that a new educator had only recently begun remote training. The absence of clear, comprehensive records and consistent training delivery led to the deficiency in staff education on resident rights and facility responsibilities.
Failure to Provide Documented QAPI Training to All Staff
Penalty
Summary
Facility staff failed to provide mandatory training to all staff on the elements and goals of the facility’s Quality Assurance and Performance Improvement (QAPI) program. During a review of the facility’s education and training records, surveyors found only a list of training topics and sign-in sheets for a skills fair, with no documented evidence that QAPI training materials or a review were actually provided to staff. Additionally, there was no documentation to show that staff who did not attend the skills fair received QAPI training. The facility’s educators were unavailable to clarify the records or provide further information regarding the training. Interviews with facility leadership confirmed that all staff are required to receive QAPI training, typically during orientation and annual skills fairs. However, upon review, the Regional Director of Operations and the Administrator were unable to substantiate that comprehensive QAPI training had been delivered, or that staff were informed about how to communicate concerns or opportunities for improvement to the Quality Assessment and Assurance (QAA) Committee. The Administrator acknowledged that staff education on QAPI was insufficient and that recent training efforts had been limited, with the new educator only providing remote sessions.
Failure to Provide Comprehensive Compliance and Ethics Training
Penalty
Summary
Facility staff failed to provide a training program or another practical method to effectively communicate the standards, policies, and procedures of the compliance and ethics program to all staff. During a review of the facility's education and training records, surveyors found only a binder containing a table of education topics, including Compliance and Ethics, with a note indicating 'Review and packet.' Attached to this document was a sign-in sheet for a skills fair, but there was no documented evidence that a structured training program was provided or that all staff, including those not present at the skills fair, received the required education on the compliance and ethics program. Interviews with facility leadership confirmed the lack of comprehensive documentation and substantiation of compliance and ethics training. The Regional Director of Operations and the Administrator both acknowledged gaps in the education process, noting that some training was provided on an as-needed basis and that a new educator had only recently started, conducting some training remotely. There was no evidence to show that the standards, policies, and procedures of the compliance and ethics program were effectively communicated to the entire staff.
Lack of Documented In-Service Training for Nurse Aides
Penalty
Summary
Facility staff failed to provide documented evidence of required in-service training for nurse aides. A review of the facility's assessment and training records revealed that only three months of in-service training for Certified Nurse Aides (CNAs) in 2024 were documented, with no staff sign-in sheets attached to the training materials. The facility's assessment stated that competencies are completed during orientation and reviewed annually, but the available records did not substantiate that all required in-service training had been provided. The facility's educators were unavailable to clarify the training records during the survey. Interviews with facility leadership confirmed the lack of comprehensive documentation for CNA in-service training. The Regional Director of Operations acknowledged that only limited training records could be found, and members of the QAA Committee stated that staff were not receiving education to the extent needed. It was also noted that some education was provided on an as-needed basis by the DON and Administrator, and that a new educator had recently been hired but had only conducted remote training. There was no evidence that the required in-service training, including dementia care and abuse prevention, was consistently provided or documented for all nurse aides.
Lack of Documented Behavioral Health Training for Staff
Penalty
Summary
Facility staff failed to provide documented evidence of an effective training program for all staff that included, at a minimum, training on behavioral health care and services for residents. During an extended survey, a review of the facility's education and training records revealed that there was no documentation showing that such training had been provided to all staff. The binder provided by the educator did not contain records of behavioral health care and services training, and the annual skills fair did not include this component. Interviews with facility leadership confirmed the lack of comprehensive behavioral health training. The Regional Director of Operations acknowledged that behavioral health training was not part of the annual skills fair and could not verify that the educator had provided this training. Members of the QAA Committee also stated that staff were not receiving the necessary education to the extent needed, and that recent training by the new educator had only been conducted remotely. There was consensus among leadership that the current approach to staff education was insufficient to meet the facility's needs.
Failure to Document Provision of Advance Directive Information
Penalty
Summary
Facility staff failed to provide documented evidence that information regarding the right to formulate or refuse an advance directive was given to five sampled residents or their representatives. The facility's policy requires that upon admission, residents or their legal representatives receive written information about their rights concerning medical treatment and advance directives, and that this information be clearly documented in the medical record. However, for the five residents reviewed, there was no such documentation present in their records. The residents involved had significant medical conditions, including encephalopathy, chronic respiratory failure, ALS, interstitial pulmonary disease, anoxic brain injury, and diabetes. In each case, the medical records included care plans referencing end-of-life wishes and interventions such as offering the facility's advance directive form (5 Wishes) quarterly. Despite these care plan entries, there was no evidence that the required information about advance directives was actually provided to the residents or their responsible parties, nor was there documentation of any follow-up if the forms were not completed. During staff interviews, the Director of Social Services confirmed that the practice was to leave the advance directive form in the resident's room and wait for it to be returned if completed, with no follow-up if the form was not returned. This lack of follow-up and documentation resulted in the facility's failure to demonstrate compliance with its own policy and regulatory requirements regarding advance directives.
Failure to Develop and Implement Comprehensive Care Plans for Residents with Specialized Needs
Penalty
Summary
Facility staff failed to develop and implement comprehensive care plans with measurable goals and interventions for multiple residents with complex medical needs. For one resident with interstitial pulmonary disease, diabetes, and a central IV line, there was no documented care plan addressing the management and care of the central IV line, despite physician orders specifying dressing changes and site monitoring. Observation revealed the dressing was not changed as scheduled, and staff acknowledged the absence of a care plan for this intervention. Another resident with a traumatic brain injury, quadriplegia, and a recent right foot fracture was provided with a foot immobilization boot following physician and therapy orders. However, the care plan did not include any focus, goals, or interventions related to the use of the immobilization boot, even though the resident was dependent for all ADLs and had a history of falls and recent surgery. Staff interviews confirmed that a care plan for the boot should have been implemented but was not. Additional deficiencies included the lack of a care plan for a resident's preference to use a Spanish-speaking interpreter during medical communication, despite documentation of this need in the MDS and direct resident statements. Another resident with an indwelling urinary catheter and recent UTI did not have a care plan addressing catheter care, even though physician orders and nursing notes documented ongoing catheter management. Finally, a resident with dysphagia and a mechanically altered diet did not have a care plan for dietary needs and feeding assistance, despite physician orders and observed feeding by staff. In each case, the absence of individualized, measurable care plans for these specific needs was confirmed through record review, staff interviews, and direct observation.
Failure to Assess and Document Resident's Self-Administration of Medication
Penalty
Summary
The Interdisciplinary Team (IDT) failed to ensure that a resident was properly assessed for the ability to self-administer an Albuterol inhaler, as required by facility policy. The resident, who had multiple diagnoses including Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Schizophrenia, and Anxiety, was observed to have moderately impaired cognitive status and required supervision with activities of daily living. Despite these factors, the resident was allowed to keep an Albuterol inhaler in her purse and self-administer it without documented assessment by the IDT to determine if this was clinically appropriate and safe. Additionally, there was no documentation in the Medication Administration Record (MAR) indicating when the resident used her inhaler over a two-week period, and staff were unable to clarify who was responsible for documenting its administration. The facility's policy required an assessment of the resident's mental and physical abilities and clear documentation responsibilities, neither of which were followed in this case. The Director of Nursing confirmed that the required assessment had not been completed.
Lack of Documentation for Verbal Abuse Allegation
Penalty
Summary
The facility failed to maintain documented evidence regarding an allegation of staff-to-resident verbal abuse involving a resident with multiple diagnoses, including altered mental status, muscle weakness, and psychotic disorder. The resident's daughter reported that a CNA made an inappropriate comment in front of her mother, which caused the resident to become afraid and express a desire to go home. The daughter stated she informed the Administrator of the incident, but could not recall the specific date. A review of the resident's medical record and the facility's incident binder revealed no documentation of the alleged verbal abuse incident. Interviews with facility staff confirmed that the CNA was suspended during an investigation into the allegation and later reassigned to a different floor. The Administrator recalled the incident and stated that an investigation was conducted, but the documentation was unavailable as it was reportedly kept by a former Human Resources Director. As a result, there was no documented evidence to show that the facility had properly investigated or addressed the allegation of verbal abuse.
Failure to Document and Justify Use of Bedrails as Restraint
Penalty
Summary
Facility staff failed to provide documented evidence that a non-ambulatory, cognitively impaired resident who required extensive assistance with bed mobility and transfers was not being restrained by the use of bedrails. The resident was observed on two separate occasions lying in bed with all four bedrails in the upward position. The resident's medical record included a physician's order for one-quarter side rails as an enabler to promote bed mobility, but there was no documentation supporting the use of all four bedrails. Additionally, the facility's own documentation requirements for physical restraints were not met, as there was no record of the date and time of restraint application, the type of restraint, the reason for use, monitoring, or assessment data. Interviews with the Administrator and Director of Nursing confirmed that the facility did not have a bedrail policy and acknowledged that the use of four bedrails would constitute a restraint, which was not supported by the resident's care plan or physician's order. The resident was dependent on staff for all bed mobility and transfers, had impairment in both upper and lower extremities, and was unable to participate in bed mobility independently. Despite these needs, the facility did not provide the required documentation or justification for the use of all four bedrails, resulting in a deficiency related to the improper use of physical restraints.
Failure to Timely Report Alleged Staff-to-Resident Verbal Abuse
Penalty
Summary
Facility staff failed to promptly report incidents of alleged staff-to-resident verbal abuse involving two residents, as required by facility policy and state regulations. In the first case, a resident with chronic respiratory failure, schizophrenia, and moderately impaired cognition was subjected to a comment by a CNA who called the resident 'crazy' for talking to himself. The incident was witnessed by another CNA who was in training but did not report the event immediately, despite having received abuse training during orientation. The incident only came to light during an investigation into a separate abuse allegation involving the same CNA and another resident. In the second case, a resident with severe cognitive impairment and multiple neurological diagnoses was allegedly verbally abused by a CNA during a care interaction. Another CNA, who was being trained by the alleged abuser, witnessed the event but did not report it at the time. The witness later disclosed the incident only when questioned during an unrelated abuse investigation. The witness expressed concerns about retaliation and lack of confidentiality, which contributed to the delay in reporting. In both cases, the facility's own investigative documents and staff interviews confirmed that the required immediate reporting to the administrator and appropriate authorities did not occur. The facility's policy mandates that all allegations of abuse be reported within two hours if abuse is involved, but this protocol was not followed. The deficiencies were identified through record reviews and staff interviews, which revealed lapses in timely reporting and adherence to established abuse reporting procedures.
Failure to Conduct Thorough Investigations of Missing Property and Abuse Allegations
Penalty
Summary
Facility staff failed to conduct thorough investigations into two separate incidents involving two residents. In the first case, a resident with mild cognitive impairment reported a missing cellphone. The facility submitted an incident report and conducted some staff interviews, but did not interview all personnel assigned to the relevant floor on the date of the incident, including housekeeping and activities staff. As a result, there was no documented evidence that a comprehensive investigation was completed regarding the missing property. In the second case, a resident with severe cognitive impairment and multiple complex medical conditions was the subject of an allegation of staff-to-resident verbal abuse. The resident's son reported overhearing a staff member use derogatory language toward his mother, but was unable to identify the specific staff member involved. The facility's investigation included interviews and written statements from staff, but the final report did not document or address two additional written statements from CNAs that alleged verbal abuse by the same staff member toward two other residents. These new allegations were not included in the final report of the original incident, despite being received before the report was submitted to the state agency. Both incidents demonstrate a lack of documented evidence that all alleged violations were thoroughly investigated as required by the facility's own policies. The failure to interview all relevant staff and to include all new findings in the final reports resulted in incomplete investigations for both the missing property and the abuse allegation.
Failure to Review and Update Care Plan After MDS Assessments
Penalty
Summary
Facility staff failed to review and implement the comprehensive person-centered care plan for one resident with multiple medical diagnoses, including dysphagia following cerebral infarction, hemiplegia, and oropharyngeal disease. Medical record review showed that after the completion of Minimum Data Set (MDS) assessments on three separate occasions—quarterly and annual assessments—there was no evidence that the care plans were reviewed or updated as required. During an interview, the Director of Social Work confirmed that the Inter-Disciplinary Team (IDT) did not review the resident's care plans following these MDS assessments.
Failure to Provide ADL Assistance for Grooming and Hygiene
Penalty
Summary
Facility staff failed to provide necessary assistance with activities of daily living (ADLs) for two residents who were unable to perform these tasks independently, resulting in deficiencies in grooming and personal hygiene. One resident, admitted with diagnoses including encephalopathy, chronic respiratory failure, and muscle weakness, required extensive assistance for ADLs. Despite a care plan intervention to check, trim, and clean fingernails on bath days and as needed, the resident was observed with long, dirty fingernails and reported having requested nail care. An LPN acknowledged awareness of the issue but did not provide an explanation for not addressing the resident's nails. Another resident, dependent on staff for all ADL care and with severe cognitive impairment, had a physician's order for a podiatry consult for nail care. Observations over several weeks showed the resident's toenails remained long and unaddressed. Review of facility records revealed the resident's name was not entered in the podiatry consult book, and the facility's podiatrist confirmed never having seen the resident or being aware of a consult order. Interviews with staff indicated that the process for arranging podiatry consults was not followed, as the resident was not added to the required list or seen by the podiatrist. These findings demonstrate that the facility did not ensure residents who were unable to perform ADLs independently received the necessary services to maintain good grooming and personal hygiene, as required by facility policy and care plans. The deficiencies were identified through direct observation, record review, and staff interviews.
Failure to Follow Professional Standards and Physician Orders in Medication Administration and Repositioning
Penalty
Summary
Facility staff failed to follow professional standards of practice and physician orders in the care of two residents. In the first instance, a registered nurse prepared a Heparin injection for a resident with a history of Deep Vein Thrombosis using an intramuscular (IM) gauge and length needle, rather than the required subcutaneous (SQ) gauge and length needle. The nurse was unable to identify the correct equipment for subcutaneous administration when questioned, and the error was only prevented by surveyor intervention before the medication was administered. In the second instance, staff did not adhere to a physician's order and care plan requiring a resident with anoxic brain injury, chronic respiratory failure, and total dependence for activities of daily living to be turned and repositioned every two hours. Observations over a three-hour period showed the resident remained on her left side with pillows for pressure redistribution, despite staff claims that repositioning had occurred. The assigned CNA was unable to explain the discrepancy when questioned and only repositioned the resident after being prompted by the surveyor. Both deficiencies were substantiated through direct observation, record review, and staff interviews, demonstrating a failure to provide care and treatment according to professional standards, physician orders, and the residents' care plans.
Failure to Administer Prescribed Water Flushes via PEG Tube
Penalty
Summary
Facility staff failed to provide a resident with water flushes via a gastrostomy tube as prescribed. The resident, who had a history of dysphagia following cerebral infarction and was dependent on tube feeding, had a physician's order for hydration water flushes of 300 milliliters every four hours. However, during an observation, it was found that the feeding pump was set to deliver water flushes every six hours instead of the ordered four-hour interval. The assigned LPN confirmed that the pump setting was incorrect and admitted not checking the tube feeding settings at the start of the shift. The resident was noted to have severely impaired cognitive status and was dependent on staff for tube feeding and hydration.
Failure to Ensure Timely and Proper Central Line Dressing Changes
Penalty
Summary
Facility staff failed to provide care and services consistent with professional standards of practice for two residents with central intravenous (IV) lines. For one resident with multiple diagnoses including interstitial pulmonary disease and chronic respiratory failure, the medical record indicated that the central line dressing was to be changed every seven days. However, during an observation, the dressing was found to be dated ten days prior, and a registered nurse confirmed that the dressing had not been changed within the required timeframe, contrary to both facility policy and physician orders. For another resident with a history of hemiplegia, hemiparesis, and anoxic brain injury, physician orders also required central line dressing changes every seven days. Documentation showed a dressing change was completed two days prior to observation, but the transparent dressing on the IV site was not labeled with the date of the last change. The unit manager acknowledged that there was no visible date on the dressing, which is inconsistent with CDC guidelines and facility policy requiring dressings to be labeled with the date of change.
Failure to Ensure Timely Physician Review of Pharmacist Recommendations
Penalty
Summary
Facility staff failed to ensure that a resident's attending physician evaluated the resident's total program of care, specifically by not providing documented evidence that the physician reviewed and acted upon pharmacist recommendations for a period of four months. The facility's Medication Regimen Review policy requires that the pharmacist report any irregularities to the attending physician, who must address these recommendations in a timely manner, no later than their next routine visit. However, for four consecutive months, there was no documentation that the physician reviewed the consultant pharmacist's medication regimen review (MRR) reports or addressed the identified irregularities for the resident. The resident in question was admitted with multiple diagnoses, including chronic pain, schizophrenia, anxiety disorder, and anoxic brain injury, and was prescribed several medications, such as antipsychotics, pain relievers, and narcotics. The consultant pharmacist's MRRs repeatedly identified issues requiring physician clarification, such as the need for specific pain scale parameters for PRN opioid orders and clarification of antipsychotic indications. Despite these recommendations being documented in the pharmacy progress notes for four consecutive months, there was no evidence in the medical record that the attending physician reviewed or acted upon them during that time frame. It was noted during staff interviews that the resident's primary doctor, who was also the medical director, left abruptly without notice, and another physician assumed care. However, the MRRs for the months in question remained unreviewed and unaddressed until a later date, resulting in a failure to ensure the physician's oversight of the resident's medication management and overall care program as required by facility policy.
Failure to Demonstrate Competency in Resident Care and Assessment
Penalty
Summary
Facility staff failed to demonstrate appropriate competencies and skills sets in the care of two residents. In the first instance, a resident with a gastrostomy tube and multiple diagnoses, including anoxic brain injury and failure to thrive, was observed with a tube feeding machine alarming due to a flow error. A CNA entered the room, performed hand hygiene, donned gloves, and attempted to restart the machine without notifying a nurse. The CNA stated that CNAs are not trained to troubleshoot gastrostomy tubes, and the DON confirmed that CNAs should not restart the machine but should alert a nurse instead. In the second instance, a resident with chronic respiratory failure, anoxic brain injury, and metabolic encephalopathy experienced tachycardia and low oxygen saturation. The assigned RN completed an SBAR form and contacted the provider, who instructed to transfer the resident to the hospital. However, the nurse failed to gather and document all relevant and pertinent information, such as current blood pressure, respirations, and temperature, at the time of the change in condition, as required by facility protocol. The DON confirmed that a complete assessment should have been performed and documented.
Failure to Ensure Availability of Ordered Medication
Penalty
Summary
Facility staff failed to ensure that a resident's prescribed medication, Levetiracetam, was available for administration as ordered. The resident, who had multiple complex medical conditions including epilepsy, spastic quadriplegia, ventilator dependence, and a gastrostomy tube, had a physician's order for Levetiracetam solution to be administered every 12 hours via gastrostomy tube. Although the medication was reordered and delivered to the facility, a nurse was unable to locate it on any of the medication carts or in the medication room during a medication pass. The facility's policy required nurses to sign the packing slip upon delivery and place the medication on the correct cart, but the medication was not available when needed. During the medication pass, the nurse attempted to use another resident's Levetiracetam to administer the dose, which was stopped by the surveyor. The nurse acknowledged that using another resident's medication was not in accordance with facility policy and indicated she would notify the nurse practitioner to obtain an order for an alternative form of the medication. The unit manager confirmed that the medication had been signed for upon delivery and should have been placed on the correct cart, but could not explain why it was missing. The staff's actions resulted in the resident's medication not being available for administration as ordered.
Failure to Ensure Timely Physician Review of Pharmacist Medication Regimen Recommendations
Penalty
Summary
Facility staff failed to ensure that a licensed pharmacist's monthly medication regimen review (MRR) recommendations and identified irregularities were reviewed and acted upon by the attending physician for one resident. The facility's policy requires that the pharmacist report any medication irregularities to the attending physician, Medical Director, and DON, and that these reports be addressed in a timely manner. For a resident with multiple complex diagnoses, including chronic pain, schizophrenia, anxiety disorder, and anoxic brain injury, the pharmacist documented several recommendations and requests for clarification regarding pain medication parameters and antipsychotic indications over a four-month period. Despite the pharmacist's repeated documentation of irregularities and recommendations in November, December, January, and February, there was no evidence in the resident's medical record that the attending physician reviewed or acted upon these reports during that time. The recommendations included clarifying PRN opioid pain medication orders with specific pain scale parameters and reviewing the indications for antipsychotic medications, as well as updating administration instructions for a lidocaine patch. These recommendations were not addressed until March, several months after they were initially made. Interviews with facility staff revealed that the delay was partly due to the abrupt departure of the resident's primary physician, who was also the Medical Director, and the subsequent transition to a new physician. However, there was no documentation or explanation for why the MRRs were not reviewed or acted upon during the four-month period, resulting in a failure to comply with facility policy and regulatory requirements for timely physician review of pharmacist-identified medication irregularities.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
Facility staff failed to maintain a medication error rate at or below 5%, as evidenced by observations of medication administration. During eight observed medication passes, there were four errors out of 25 opportunities, resulting in a 16% medication error rate. Staff interviews confirmed that education on medication administration and management is provided.
Failure to Properly Store and Dispose of Insulin Medications
Penalty
Summary
Facility staff failed to ensure the safe and secure storage of medications, specifically insulin, as required by professional standards and manufacturer guidelines. Surveyors observed multiple opened and undated vials of insulin, as well as expired insulin vials, stored in medication refrigerators on two separate floors. In one instance, an opened and expired vial of Humalog Mix 75/25 insulin was found in the medication room refrigerator, with documentation showing it had been opened over a month prior and administered to a resident beyond the recommended 28-day usage period. The medication administration record confirmed that expired insulin was given to the resident for at least two days. Additional observations revealed further deficiencies in medication storage practices. On another floor, surveyors found an opened vial of Aspart insulin with no expiration date, two opened vials of Lantus insulin with no dates, and an opened Lantus insulin pen belonging to a discharged resident, all stored in the medication refrigerator. Review of medication records indicated that some of these insulins had not been administered for weeks or months, and in one case, a discharged resident's insulin pen remained in storage for nearly two months after discharge. Manufacturer guidelines for all insulins observed require disposal 28 days after opening, regardless of remaining volume or storage conditions. Interviews with nursing staff and unit managers confirmed that responsibility for checking and removing expired or undated medications from storage was not consistently followed. Staff acknowledged that they had not noticed expiration dates or failed to remove medications for discharged residents. The lack of proper dating, timely removal, and disposal of expired or unused insulin vials and pens directly led to the deficiencies cited in the report.
Failure to Provide Mechanically Altered Diet as Prescribed
Penalty
Summary
Facility staff failed to provide food in a form designed to meet the individual needs of a resident who was prescribed a mechanically altered, soft and bite-sized pleasure diet due to multiple medical conditions, including dysphagia, oropharyngeal disease, and loss of teeth. The resident, who received gastrostomy tube feedings for nutrition and required maximum assistance with eating, was observed with a lunch tray containing roast beef chunks that were not mechanically altered to the prescribed bite-sized texture. The assigned CNA was preparing to feed the resident but was unable to confirm if the food was appropriate for the resident's diet. Upon further review, the speech pathologist assessed the tray and determined that the roast beef pieces exceeded the required bite-sized specification, stating that this was unsafe for the resident. The dietician was also unsure if the food met the prescribed requirements. The Director of Food and Nutrition later acknowledged that the resident had been served a regular diet instead of the ordered bite-sized diet, confirming an error in meal preparation and delivery for this resident.
Deficiencies in Kitchen Sanitation and Equipment Maintenance
Penalty
Summary
During a kitchen inspection, staff failed to maintain sanitary conditions in food storage, preparation, and distribution areas. Observations included an open, undated bag of shredded carrots stored in the walk-in freezer, torn air/strip curtains in the walk-in refrigerator/freezer, and soiled ceiling light covers above the three-compartment sink. Additionally, an open bottle of eyewash solution with a broken sterility seal was found near the tray line, and one of two garbage disposal units was inoperative. Two steamers and one food warmer had been out of service for extended periods, further impacting the facility's ability to properly prepare and serve food. In the dry storage room, an expired nutritional drink was found, several ceiling lights were missing protective tube guards, and a ceiling tile had been removed and not replaced. These deficiencies were acknowledged by a facility employee during an interview. The report does not mention any specific residents or their medical conditions in relation to these findings.
Failure to Meet Minimum Daily Nursing Care Staffing Ratios
Penalty
Summary
The facility failed to comply with State Regulation 22B DCMR sect. 3211.5 by not providing the required minimum daily average of 4.1 hours of direct nursing care per resident per day, with at least 0.6 hours provided by a registered nurse, on seven out of thirty-five sampled days. Review of daily staffing sheets showed that on multiple days, the facility's resident census ranged from 104 to 110, but the direct nursing care hours provided fell below the mandated threshold, with some days as low as 3.3 hours per resident and registered nurse hours also falling short. During an interview, the staffing coordinator acknowledged staff shortages on these days due to ongoing hiring efforts and admitted to being unaware of the specific staffing requirements.
Inaccurate Medical Record Documentation After Resident Transfer
Penalty
Summary
Facility staff failed to maintain accurate documentation in the medical record of a resident who was admitted with chronic respiratory failure, anoxic brain injury, and metabolic encephalopathy. On the morning of the incident, the resident experienced tachycardia and low oxygen saturation, prompting a nurse practitioner to direct transfer to the hospital, which occurred around 9:00 AM. Despite the resident's transfer, the Medication and Treatment Administration Record for that night shift contained documentation indicating that vital signs were taken and medications and treatments were administered to the resident, who was no longer present in the facility. This discrepancy was confirmed through staff interviews and review of the medical record.
Failure to Follow Infection Control and Enhanced Barrier Precaution Protocols
Penalty
Summary
Facility staff failed to follow established infection prevention and control practices for multiple residents requiring enhanced barrier precautions and specialized care. In one instance, a registered nurse administered insulin to a resident with Type 2 Diabetes Mellitus and, after removing gloves, did not perform hand hygiene before leaving the room and documenting in the electronic health record. The facility's policy for subcutaneous injections specifically instructed staff to perform hand hygiene after glove removal, but this step was omitted. Additionally, staff did not adhere to enhanced barrier precaution protocols for residents with complex medical needs. For a resident with an ileostomy, a registered nurse washed hands and donned gloves before emptying the ileostomy container but failed to put on a gown as required by the posted enhanced barrier precaution signage. The nurse acknowledged awareness of the protocol but did not follow it during the observed care activity. A similar lapse occurred with a resident who had a urinary catheter and required enhanced barrier precautions. A certified nurse aide washed hands and wore gloves to empty the urinary catheter container but did not wear a gown as directed by the signage. In another case, an LPN entered the room of a resident with a gastrostomy tube and did not perform hand hygiene before entering or after exiting the room, despite the enhanced barrier precaution requirements. In each instance, staff acknowledged the missed steps when interviewed immediately after the observations.
Failure to Maintain Pest-Free Environment in Food Service Areas
Penalty
Summary
Facility staff failed to maintain an environment free of pests, as evidenced by the presence of multiple mouse traps and mouse droppings in key food preparation and cleaning areas. Specifically, three mouse traps were observed around the cook line, including behind the grill and gas stove, and another mouse trap with mouse droppings was found in a corner of the dishwashing machine room. Additionally, flying insects, identified as gnats, were observed in the area of the three-compartment sink and sporadically throughout the kitchen. These findings were acknowledged by a facility employee during an interview.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
Facility staff failed to implement its policy by not having documented evidence they conducted a background check or that an employee received abuse education. Resident #70, who was admitted with multiple diagnoses including Quadriplegia and Spinal Stenosis, reported that an RN screamed at him. During the investigation, it was found that the facility had no HR file or documentation for the RN, who was an agency nurse. The RN worked at the facility from January 2021 to December 2022 and was terminated after the incident. The Director of Human Resources, who started in March 2023, confirmed the lack of documentation and stated that she has since ensured all employees have proper files with HR. Facility staff also failed to remove the alleged perpetrator from the facility to protect the alleged victim pending an investigation. Resident #31, who was admitted with diagnoses including Hemiplegia and Vascular Dementia, reported that a CNA called her 'pathetic.' The facility initiated an investigation and documented the incident, but the CNA continued to work at the facility from 10/12/23 to 10/14/23 and returned to work on 10/18/23. The CNA stated that the resident was verbally abusive towards her, and the RN confirmed that the resident agreed to allow the CNA to assist with feeding. However, the RN acknowledged that the CNA should have been reassigned due to the abuse allegation. The evidence showed that the facility staff failed to follow their policies regarding abuse prevention and investigation. They did not have documented evidence of background checks or abuse education for the RN involved in Resident #70's case. Additionally, they did not remove the CNA from Resident #31's care during the investigation, which was against their policy to ensure the protection and safety of the resident.
Failure to Provide Bed-Hold Policy Information Before Hospital Transfers
Penalty
Summary
The facility staff failed to provide written information to the resident or resident representative regarding the duration of the State Agency's bed-hold policy before transferring three residents to the hospital. Resident #2, who had severe cognitive impairment, was transferred to the hospital after a fall, but the facility did not provide the resident's representative with written notice of the bed hold days before the transfer. The Social Worker acknowledged that the form should have been completed on the same day as the transfer and should have included the number of bed hold days available to the resident. Resident #310, who was cognitively intact, was transferred to the hospital after a fall that resulted in a deep cut under the chin. The facility staff did not provide the required 6-108 form documenting the bed hold days before the transfer. The Director of Social Services confirmed that the document was not found for the resident's transfer to the hospital. Resident #34, who was also cognitively intact, was transferred to the hospital due to chest pain. The facility staff failed to provide the resident with written information specifying the duration of the state bed-hold days before or within 24 hours of the transfer. The notice was only provided upon the resident's readmission to the facility. The Director of Social Services admitted that the notice of transfer form was completed late, attributing the delay to the New Year's holiday.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility staff failed to develop a comprehensive care plan for Resident #54, who was admitted with a history of Cerebral Palsy, Asthma, Seizure, Anemia, Atrial Fibrillation, and Sepsis. Despite a physician's order for Foley catheter care every shift, the resident's care plan lacked documented evidence of goals and approaches for the use of an indwelling urinary catheter. The resident, who had severe cognitive impairment and was dependent on staff for bed mobility, transfers, and toilet use, did not have a care plan addressing the catheter. This deficiency was confirmed during a face-to-face interview with the Director of Nursing, who acknowledged the absence of the required care plan.
Failure to Prevent Dislodgement of Suprapubic Catheter
Penalty
Summary
The facility's staff failed to ensure appropriate care to prevent a resident's suprapubic catheter from becoming dislodged during care. Resident #362, who was admitted with multiple diagnoses including Functional Quadriplegia and Neurogenic Bladder, had a care plan in place to prevent catheter-related trauma. Despite this, the resident's suprapubic catheter was dislodged during care by a Certified Nurse's Aide (CNA), resulting in small bleeding at the stoma site. The incident was documented in a Situation, Background, Assessment, Request Form and a Root Cause Analysis identified possible improper handling of the catheter as the cause. The Director of Nursing (DON) confirmed that the catheter should not have been dislodged during care and stated that the CNA involved was re-inserviced on handling durable medical equipment gently. The incident was also documented in a State Survey Agency Intake Form, which noted that the resident's mother and the medical doctor were informed, and a new suprapubic catheter was inserted aseptically per facility guidelines. The resident tolerated the procedure well, and the catheter was draining as expected.
Failure to Ensure Effective Pain Management
Penalty
Summary
Employee #5, a Licensed Practical Nurse (LPN), failed to ensure that Resident #46 received effective pain management in accordance with the physician's orders and the comprehensive care plan. Resident #46, who was admitted with diagnoses including Chronic Pain Syndrome, Chronic Obstructive Pulmonary Disease (COPD), and Retention of Urine, had a physician's order for Acetaminophen to be administered as needed for pain. On two separate dates, 01/01/24 and 01/08/24, the resident reported high pain levels of 9 and 10 on the numerical scale, but there was no documented evidence in the Medication Administration Record (MAR) or progress notes that the resident was medicated for pain during these times. The resident's pain assessments later showed a pain level of 0, indicating that the pain was eventually managed, but the lack of documentation suggests a failure in following the prescribed pain management protocol. During an interview, Employee #5 stated that they assessed the resident's pain and administered the PRN medication as required, but could not explain why it was not documented in the MAR. The absence of documentation and the failure to provide timely pain relief as per the physician's orders and care plan highlight a significant lapse in the resident's pain management. This deficiency was observed during the day shift on both dates, where the LPN was responsible for the resident's care, yet failed to provide the necessary pain relief or document any refusal of medication by the resident.
Failure to Demonstrate Competency in Medication Administration
Penalty
Summary
Facility staff failed to demonstrate competency in administering medications via feeding tubes, compromising resident safety. During an observation, a surveyor noted that an LPN had pre-poured and pre-crushed medications into plastic cups for five residents. The LPN admitted to doing this to prevent G-tube clogging, despite acknowledging that it was not the standard practice. This practice contradicts guidelines from the National Library of Medicine and CMS, which state that medications should be administered separately and not pre-poured to avoid drug interactions and errors. The Unit Manager confirmed that medications should not be pre-crushed or pre-poured ahead of time and should be administered as ordered to each resident before signing off. The evidence showed that the LPN's actions were not in line with the facility's medication administration protocols, indicating a lack of competency in providing appropriate nursing services to ensure resident safety.
Failure to Follow Controlled Medication Reconciliation Procedures
Penalty
Summary
Facility staff failed to ensure that the system to account for the reconciliation of controlled medications was followed. During an observation of Medication Cart B on the 5th Floor, it was noted that the January 2024 Controlled Medication Shift Change Log had multiple entries left blank. Specifically, entries for dates ranging from 01/01/24 to 01/11/24 were missing documentation of whether the narcotic count was correct and lacked signatures from both off-going and on-coming nurses. Employee #7, an LPN, admitted to forgetting to circle 'yes' on the sheet for the 01/11/24 count and was unsure why the off-going nurse did not sign out. During a face-to-face interview, the DON acknowledged the findings and confirmed that the process requires both out-going and in-coming nurses to perform the narcotic count, ensure its correctness by circling yes or no, and sign their names. The evidence showed that the facility staff did not follow the established system for accounting for the reconciliation of controlled medications.
Failure to Serve Cold Food at Proper Temperature
Penalty
Summary
The facility failed to serve cold food (pineapples and pears) at or below 41 degrees Fahrenheit for two separate instances. On 01/11/24 at 1:19 PM, a test tray on the 4th floor revealed a cup of pineapples that had a temperature of 51 degrees Fahrenheit. During a face-to-face interview at 1:20 PM, the Chef acknowledged the findings. On 01/12/24 at 12:59 PM, a test tray on the 4th floor revealed a cup of pears that had a temperature of 53 degrees Fahrenheit. During a face-to-face interview at 1:00 PM, the Chef acknowledged the findings. The Food Service Director later stated that they would order cooling bowls with lids to serve cold food.
Failure to Maintain Administrative Records for Agency RN
Penalty
Summary
Facility staff failed to operate and provide services in compliance with applicable State regulations regarding professionals providing services in the facility. Specifically, the facility did not maintain an administrative record for an agency RN who worked at the facility from January 2021 to December 2022. This is in violation of 22B DCMR sec. 3203.7, which requires that each administrative record be retained for at least five years from the date of creation. The deficiency was identified during an investigation of a Facility Reported Incident (FRI) where a resident reported that the RN screamed at him for refusing to be turned. Upon review, it was found that there was no file or documentation for the RN in the human resources records. The Director of Human Resources confirmed that no records existed for the RN, who was terminated after the incident. This lack of documentation indicates a failure to comply with state regulations regarding record retention.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,232 citations issued within 25 miles in the last 12 months — including the 12 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Unique Rehabilitation And Health Center Llc | 1.1 mi | ★★★★★ | 3 | 0 |
| Washington Ctr For Aging Svcs | 2.3 mi | ★★★★★ | 2 | 0 |
| Capitol City Rehab And Healthcare Center | 2.7 mi | ★★★★★ | 32 | 0 |
| Inspire Rehabilitation And Health Center Llc | 3 mi | ★★★★★ | 17 | 0 |
| Jeanne Jugan Residence | 3.2 mi | ★★★★★ | 0 | 0 |
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