Bridgepoint Subacute And Rehab Capitol Hill
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 223 7th Street Ne, Washington, District Of Columbia 20002
- CMS Provider Number
- 095027
- Inspections on file
- 21
- Latest survey
- May 5, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Bridgepoint Subacute And Rehab Capitol Hill during CMS and state inspections, most recent first.
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.
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.
Latest citations in District Of Columbia
Facility staff did not provide required Notices of Medicare Non-Coverage (NOMNC) at least two days before the end of Medicare Part A services for two Medicare beneficiaries. In one case, the resident’s representative received the NOMNC by email only one day before rehab services ended. In the other case, a resident signed the NOMNC on the last covered day of Part A services. During interview, the social worker confirmed that NOMNCs for these residents were not issued 48 hours in advance of the termination of covered services.
Surveyors found that the facility did not ensure required monthly medication regimen reviews were consistently documented and that physician responses to pharmacist recommendations were obtained. For one resident with dementia, diabetes, hypertension, and chronic kidney disease who was receiving PRN oxycodone for severe pain, there was no documented monthly medication review for a specific month despite facility policy requiring monthly pharmacist review. For another resident with COPD, dementia with mood disturbance, depression, and multiple psychotropic and related medications, the consultant pharmacist documented concerns about psychotropic polypharmacy and recommended a psychiatric consult and consideration of gradual dose reductions, but the record contained no documented physician or prescriber response. The RN/Clinical Nurse Manager described a process for routing MRRs to physicians but could not locate a response for this resident’s review or explain how missed MRRs were prevented.
Staff failed to maintain sanitary conditions in food storage, preparation, and dishwashing areas, including undated opened shredded cheese, expired milk with settled contents, condensation leaking onto frozen food, and significant food residue on equipment and floors. A kitchen manager checked tuna salad temperature before handwashing, a dishwashing employee used a towel to dry sanitized kitchenware, and mold and limescale were present in the dishwashing area. Pest control reports had previously cited food debris and inadequate cleaning under and behind kitchen equipment and drains. During a follow-up visit, employee personal belongings were stored on racks in the dry storage room, creating potential cross contamination with food and food-contact surfaces.
Staff failed to document required nursing care and treatments for two residents, resulting in incomplete medical records. One resident with dementia, Parkinson's disease, and severe malnutrition had a standing order for aspiration precautions every shift, but the TAR lacked documentation that these precautions were provided on two shifts. Another resident with respiratory and pain-related diagnoses had orders for non-skid socks during the evening shift for fall risk and for heel elevation/floating on pillows for pressure relief every shift while in bed, yet the TAR showed no evidence these interventions were documented on multiple evening shifts. A CNM acknowledged the missing documentation and uncertainty about whether chart checks include verifying completion of ordered care.
Staff failed to maintain essential kitchen equipment when the condensation pipe carrying condensate wastewater from the air condenser in the walk-in freezer was found leaking during a kitchen tour. The issue was confirmed in an interview with the kitchen manager and the corporate chef, who acknowledged the ongoing leak in the freezer’s condensation piping.
Facility staff did not maintain an effective pest control program in the kitchen, as evidenced by surveyor observations of multiple live flies at the juice counter and dishwashing areas during a tour. Pest control reports from an external vendor months apart documented repeated needs for general cleaning under and behind cooking equipment, along walls, around floor drains in the dish room, and under the juice counter due to food debris and uncleaned areas. During an interview, the corporate chef and kitchen manager acknowledged the presence of flies and the observed conditions.
A resident with dementia and documented high elopement risk, including orders for a wander guard and care plan interventions requiring staff to know her whereabouts at all times, was able to leave a secure Memory Care unit after a pantry door near the exit was left open by dietary staff. Video showed the resident moving from the dining area into the pantry and then out through the open pantry door to an unsecured area, passing security staff and exiting the building without staff awareness. The resident had previously cut off her wander guard bracelet using scissors she had obtained and concealed in her belongings. Nursing leadership later acknowledged that the care plan directive to know the resident’s whereabouts "at all times" had been operationalized as hourly checks, and staff did not maintain continuous awareness of the resident’s location, resulting in an elopement and an Immediate Jeopardy finding under F689.
Staff did not follow a physician’s order that, per a resident’s request, no male CNA be assigned on any shift. The resident had dementia, CHF, HTN, and age-related macular degeneration and required supervision or touching assistance with personal hygiene. Review of assignment sheets and CNA documentation over several weeks showed that a male CNA was repeatedly assigned and documented as providing care on multiple shifts, despite the standing order and staff awareness of the restriction.
Surveyors found that the facility failed to post its most recent survey results in an area readily accessible to residents, families, and representatives, and did not maintain survey reports from the prior three years for review upon request. A binder labeled as containing entrance survey results near the front desk held only older survey documents, and the receptionist could not identify where current State Agency survey results were kept. During a Resident Council meeting, residents reported they were unaware that State inspection results were available or where to locate them without asking, and there was no evidence that current survey reports, complaint investigations, or plans of correction were accessible to the public.
Staff did not maintain a safe and well-kept environment in the kitchen dry storage area. During a survey walkthrough, damaged drywall and a missing baseboard were observed in the dry storage room, and the Food Service Manager acknowledged these conditions.
Failure to Provide Timely NOMNC Prior to End of Medicare-Covered Services
Penalty
Summary
Facility staff failed to provide required Notices of Medicare Non-Coverage (NOMNC), Form CMS-10123, at least two days before the end of Medicare-covered services for two Medicare beneficiaries. Record review on 03/24/2026 at approximately 4:35 PM showed that for one resident, the skilled services episode began on 09/04/2025 with the last covered day of Part A services on 09/25/2025. An email exchange in the clinical record dated 09/24/2025 at 10:14 AM between the social worker (Employee #5) and the resident’s representative included an attached notice stating that the resident’s rehab services were ending the next day under that version of Medicare. The NOMNC documentation showed the representative acknowledged the notice via email on 09/24/2025 at 12:52 PM, confirming that the notice was not provided at least two days before the end of covered services. For a second resident, record review showed a skilled services episode start date of 08/29/2025 and a last covered day of Part A services of 09/22/2025. The NOMNC form for this resident contained the resident’s printed full name and a date of 09/22/2025 on the signature line, indicating the notice was given on the last covered day rather than at least two days in advance. During a face-to-face interview on 03/24/2026 at approximately 4:35 PM, the social worker (Employee #5) confirmed that the NOMNCs for both residents were not sent 48 hours before the end of covered services, acknowledging that the facility did not provide timely notification of changes to Medicare-covered items and services for these residents.
Failure to Complete Monthly Medication Reviews and Obtain Physician Response to Pharmacist Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the consultant pharmacist completed and documented a monthly medication regimen review (MRR) for one resident and the failure of a physician or prescriber to respond to the pharmacist’s recommendations for another resident. Facility policy titled “Medication Review,” reviewed on 02/11/2026, required the consultant pharmacist to review each resident’s medication regimen monthly. One resident, admitted with diagnoses including Diabetes Mellitus, Dementia, Hypertension, and Chronic Kidney Disease, had an order for oxycodone 5 mg every six hours as needed for severe pain and an admission MDS showing a BIMS score of 03, indicating severe cognitive impairment. Review of this resident’s medical record from September 2025 through February 2026 showed no documented evidence of a monthly medication review for October 2025. During a telephone interview, the consultant pharmacist acknowledged that she should have made a note for every resident every month, confirmed that no note was present in the electronic health record for October, and stated it may have been an error on her part. For another resident, admitted with diagnoses including COPD, dementia with mood disturbance, Type 2 Diabetes Mellitus, depression, and generalized muscle weakness, the medical record contained multiple psychopharmacologic and related medications, including donepezil, trazodone, diazepam (in two different doses and schedules), Fetzima, Abilify, and Remeron. A Medication Regimen Review dated 12/08/2025 documented the pharmacist’s recommendation for a regular psychiatric consult to monitor therapy efficacy and side effects and to consider gradual dose reductions due to polypharmacy of psychopharmacological medications. The clinical record lacked documented evidence of any physician or prescriber response to this recommendation. In an interview, the RN/Clinical Nurse Manager described the process for handling MRR recommendations—receiving them by email, printing and flagging them in the paper chart for physician response, and then filing them in a binder—but was unable to locate the physician’s response to the 12/08/2025 MRR and did not explain how she ensured that no residents’ MRRs were missed.
Unsanitary Food Storage, Preparation, and Dishwashing Practices in Kitchen
Penalty
Summary
Facility staff failed to prepare and distribute food under sanitary conditions in the kitchen and dishwashing areas. During an initial kitchen survey, surveyors observed an undated opened bag of shredded cheese in the refrigerator and multiple half-gallon milk containers in a reach-in refrigerator that were past their sell-by dates, with contents appearing settled. In the walk-in freezer, condensation water was leaking onto packaged potato fries. A kitchen manager checked the temperature of tuna salad before washing hands. Surveyors also noted significant food residue buildup on cooking equipment and floors in both the cooking and dishwashing areas, as well as excessive limescale accumulation on the interior surfaces of the automatic dishwashing machine. A dishwashing employee used a towel to dry food-contact surfaces of washed and sanitized kitchenware, and mold was present on wall surfaces and caulk lines in the automatic dishwashing area. Pest control reports from an outside company documented prior findings that the kitchen floor areas along walls, under equipment on the cooking line, behind cooking equipment, under the three-compartment sink in the dish room, and under the juice counter contained food debris and needed cleaning, and that a small center drain on the cooking line needed to be cleaned. During a follow-up kitchen survey, employee personal belongings, including a jacket and backpack, were observed stored on racks in the dry storage room rather than in a designated locker area, creating a potential for cross contamination of food and food-contact surfaces stored there. These conditions and practices collectively demonstrate a failure to maintain food storage, preparation, and distribution in accordance with sanitary and professional standards.
Failure to Document Ordered Aspiration, Fall, and Pressure Injury Precautions
Penalty
Summary
Facility staff failed to maintain complete and accurate medical records and to document nursing care and treatment as ordered for two residents. For one resident with dementia, Parkinson's disease, and severe protein-calorie malnutrition, a physician's order dated 01/23/26 required aspiration precautions every shift. The resident’s Significant Change MDS showed a BIMS score of 03, indicating severely impaired cognition. Review of the Treatment Administration Record (TAR) for March 1–31, 2026 showed no documented evidence that aspiration precautions were provided on the night shift of 03/07/26 and the evening shift of 03/18/26, despite the standing order. For another resident admitted with respiratory failure, pneumonia, asthma, and chronic back pain, a physician’s order dated 02/06/26 required non-skid socks during the evening shift for fall risk and elevation/floating of heels on pillows for pressure relief every shift while in bed. The admission MDS documented a BIMS score of 13, indicating the resident was cognitively intact and required supervision with ADLs. Review of the TAR for February 1–28, 2026 revealed no documented evidence that non-skid socks were applied during the evening shift, or that the resident’s heels were elevated/floated on pillows for pressure relief, on 02/07/26, 02/13/26, 02/21/26, and 02/22/26. In an interview, the Clinical Nurse Manager acknowledged the findings and stated that night shift normally performs 24-hour chart checks for new orders but was unsure if they verify that ordered care is documented as completed.
Failure to Maintain Walk-In Freezer Condensation System
Penalty
Summary
Facility staff failed to maintain essential kitchen equipment, specifically the walk-in freezer, in good working order. During the initial kitchen tour on 03/24/2026 at approximately 10:15 AM, surveyors observed that the condensation pipe conveying condensate wastewater from the air condenser in the walk-in freezer was leaking. In a face-to-face interview conducted shortly thereafter on 03/24/2026 at approximately 10:30 AM, the Kitchen Manager (Employee #6) and the Corporate Chef (Employee #7) acknowledged the observed leak from the condensation pipe in the walk-in freezer.
Failure to Maintain Effective Kitchen Pest Control and Sanitation
Penalty
Summary
Facility staff failed to maintain an effective pest control program to keep the kitchen free of pests, specifically flies. During an initial kitchen tour on 03/24/2026 at approximately 10:15 AM, surveyors observed multiple live flies at the juice counter and dishwashing areas. Review of a pest control report from Bay City Pest Management Co. Inc. dated 02/19/2026 documented that, although the kitchen was inspected, general cleaning was needed under equipment on the cooking line, along the wall and floor drain under the 3-compartment sink in the dish room, and in the corner area of the floor under the juice counter. A prior pest control report dated 07/18/2025 similarly noted that the floor area along the wall under counters and behind cooking equipment needed to be cleaned due to a lot of food debris, and that a small center drain on the cooking line needed cleaning. During a face-to-face interview on 03/24/2026 at approximately 10:15 AM, the Corporate Chef (Employee #7) and Kitchen Manager (Employee #6) acknowledged the observations of flies in the kitchen. No residents or their clinical conditions were mentioned in the report, and the deficiency centers on environmental sanitation and pest control practices in the kitchen area.
Elopement from Memory Care Unit Due to Inadequate Supervision and Open Pantry Door
Penalty
Summary
Facility staff failed to ensure adequate supervision and adherence to a person-centered care plan for a resident identified as an elopement risk, resulting in the resident eloping from a secure Memory Care unit. The resident had multiple diagnoses including dementia, congestive heart failure, hypertension, and age-related macular degeneration, and had physician orders for behavioral monitoring related to elopement and for use of a wander guard (code alert) with checks for placement and functioning every shift. An elopement risk screening showed a high-risk score, and the care plan documented that the resident was at risk for elopement related to poor safety awareness, hoovered around the main exit door with a friend waiting for someone to allow them to leave, and was on high alert for elopement. Care plan interventions included following the community elopement evaluation and monitoring process, keeping the resident safe on the locked unit, replacing the wander guard bracelet as soon as it was known the resident had removed it, and that nursing would check and know the whereabouts of the resident at all times. On the day of the incident, documentation showed that the wander guard system had been checked and passed, and a safety checklist entry indicated that the resident was observed in her room at 11:00 AM. However, video recordings later showed that at approximately 11:40 AM, a food service manager entered the first-floor pantry near the Memory Care unit entry/exit doors and left the pantry door wide open. Shortly thereafter, the resident approached the dining room doors near the main entry/exit doors of the unit and hovered there while a food pantry worker was inside the pantry. The pantry worker exited through the dining room side pantry door, and the resident then opened the dining room doors, entered the dining room, and proceeded into the pantry. The video further showed that the resident exited the still-open pantry door located outside of the Memory Care unit, pushing her rolling walker, without staff knowledge. The resident then walked past two security officers in the main lobby, now without a walker and holding a jacket and a bag, and proceeded outside the facility’s main entry/exit doors. A nurse supervisor was later called by security to identify a person outside with a bag and recognized the individual as the resident from the Memory Care unit. The resident was resisting returning inside and was brought back with assistance from nursing staff, after which a head-to-toe assessment was completed with no abnormalities noted. Interviews revealed that an LPN had previously placed and tested a wander guard bracelet on the resident, but after the incident staff discovered that the resident had obtained scissors and used them to cut off the bracelet, hiding the scissors and cut bracelet in her pocketbook. The DON acknowledged that the care plan intervention stating that nursing would check and know the whereabouts of the resident at all times had been interpreted as hourly checks, and could not clearly explain what “at all times” meant beyond stating that staff frequently had eyes on the resident. The evidence showed that staff did not check and know the resident’s whereabouts at all times, and that the resident was able to elope from the secured unit without staff awareness, leading to identification of an Immediate Jeopardy at F689. An Immediate Jeopardy (IJ-J) to resident health and safety was identified at 42 CFR 483.25, F689, on 03/18/26 at 1:12 PM based on these failures in supervision and implementation of the care plan, including failure to ensure the resident’s whereabouts were known at all times and failure to prevent elopement from a secure area.
Removal Plan
- Resident #1 was brought safely back into the facility by the Supervisor and first floor staff after being observed outside unsupervised.
- Upon re-entering the first floor, Resident #1 received a head-to-toe assessment by the charge nurse and supervisor and no abnormalities were noted.
- Resident #1's care plan was revised to increase monitoring of her location/whereabouts to every 30 minutes.
- Resident #1 is utilizing a wanderguard bracelet that will trigger both doors to the memory care unit.
- Resident #1 no longer has access to scissors used to remove the wanderguard; scissors were removed.
- The charge nurse notified Resident #1's legal guardian about the incident and that the resident cannot have access to scissors.
- Dining staff were educated by the Dining Manager on the importance of locking the pantry door when no one is in the pantry.
- Maintenance made the pantry door used for elopement inoperable so no one could enter/exit through that door; pantry access remained available via the dining room door for emergencies.
- Keypads were installed on both pantry doors so they cannot be opened unless the code is entered.
- A 100% audit of all residents at risk for elopement was conducted to ensure behavior monitoring for wandering/exit-seeking was in place.
- All residents identified as elopement risk and exit-seeking were to have care plans updated to reflect increased monitoring every 30 minutes.
- All residents identified as elopement risk were to have a wanderguard applied with an order to check placement and functioning every shift.
- All residents identified as elopement risk were to have a care plan identifying elopement risk and person-centered interventions to prevent unaccompanied leaving.
- All residents identified as elopement risk were to have orders in place to check wanderguards for placement and functioning every shift.
- All employees were to be re-educated on ensuring doors that should not be left open/unlocked are properly closed and locked after entry/exit.
- All charge nurses were to be re-educated on checking wanderguard placement and functioning, including methods to verify function.
- All nursing staff were to be educated on increasing monitoring for residents at risk for elopement from every hour to every 30 minutes.
- All charge nurses were to be educated on documenting the location of the resident's wanderguard when checking placement and functioning.
- Facility implemented a systemic change to increase monitoring for residents at risk for elopement and exit-seeking from every 1 hour to every 30 minutes.
Failure to Follow Physician Order Regarding CNA Gender Assignment
Penalty
Summary
Facility staff failed to follow a physician’s order specifying that Resident #1, who had dementia, congestive heart failure, hypertension, and age-related macular degeneration, was not to be assigned a male CNA on any shift per the resident’s request. The physician’s order, dated 07/28/24, directed that every shift the resident was to have no male CNA, and a quarterly MDS assessment documented a BIMS score of 10, indicating moderately impaired cognition, and a need for supervision or touching assistance with personal hygiene. Review of nursing assignment sheets and CNA documentation from 02/01/26 to 03/18/26 showed that, despite this order, a male CNA was assigned to and documented as providing care to the resident on multiple dates and shifts, totaling 15 shifts during this period. During a face-to-face interview on 03/19/26 at 9:40 AM, the surveyor presented these findings to the Assistant Director of Nursing and the 1st floor Unit Manager, and the Unit Manager acknowledged that staff were aware that a male should not be assigned to this resident.
Failure to Maintain and Post Accessible Survey Results for Residents and Public
Penalty
Summary
Facility staff failed to post the results of the most recent survey in a place readily accessible to residents, family members, and resident representatives, and failed to maintain survey reports from the three preceding years for review upon request. During an observation and interview with the front desk receptionist, the employee was unable to identify where the most recent State Agency survey results were kept and had to contact the Administrator for clarification. A binder labeled "Entrance Survey Results Book" was observed near the front entrance, but it only contained survey results from 2022, including a recertification and annual licensure survey, a licensure survey, an emergency preparedness and life safety code survey, and a federal comparative life safety code survey. No recent state or federal surveys were present in the binder at that time. During a Resident Council meeting, residents reported that they did not know that State inspection results were available to read or where to find them without having to ask. At the time of the observations and interviews, there was no evidence that the facility had posted the results of its most recent survey in an area readily accessible to residents, families, and resident representatives. Additionally, the facility did not have available, upon request, its survey reports for the prior three years, including certification surveys, complaint investigations, and any plan of correction in effect, and these reports were not maintained in areas easily accessible to the public.
Failure to Maintain Safe and Well-Maintained Kitchen Dry Storage Area
Penalty
Summary
Facility staff failed to maintain a safe, clean, comfortable, and homelike environment when damage to the physical environment in the kitchen dry storage room was not addressed. During an initial kitchen walkthrough on 03/02/2026 at approximately 11:15 AM, surveyors observed damaged drywall and a missing baseboard in the dry storage room. In a face-to-face interview conducted at the same time, the Food Service Manager (Employee #14) acknowledged the presence of the damaged drywall and missing baseboard in the dry storage area.
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