Capitol City Rehab And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 2425 25th Street Se, Washington, District Of Columbia 20020
- CMS Provider Number
- 095022
- Inspections on file
- 23
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Capitol City Rehab And Healthcare Center during CMS and state inspections, most recent first.
Two residents experienced head injuries due to inadequate accident prevention measures and supervision. One resident with mobility limitations and confusion was readmitted and left unattended in a bed that staff knew was stuck in a high position; the bed was not lowered or otherwise made safe before the resident attempted to get to a chair and fell, sustaining a forehead injury. Another resident with muscle weakness, hemiparesis, and moderate cognitive impairment, who required two‑person assist for showers, was turned toward a wall and grab bar in a small shower room; with staff hands slippery from soap, the resident struck his head on the wall/grab bar, causing forehead swelling. The CNA involved acknowledged the room was too small for two staff and did not initially report the fall to the nurse.
Surveyors found that survey results were not readily accessible to residents and families. A binder labeled “Survey Results” was stored behind the receptionist’s desk in the lobby, rather than in a public area. The receptionist reported that this binder is always kept behind the desk and is only given to individuals if they specifically request to view it, meaning survey results could not be examined without asking staff.
Staff did not develop or implement a comprehensive, person-centered care plan to address a resident’s documented egg allergy and preference for double portions at meals. The resident, who had multiple medical conditions including DM and ESRD and was cognitively intact, had a therapeutic diet order and clearly documented allergies and double-portion instructions on meal tickets. Despite this, the care plan did not include the egg allergy or double-portion preference, and the resident reported repeatedly receiving eggs and not receiving double portions, supported by photos of meal tickets and trays. The DON stated that care plans are implemented by clinical staff based on identified focus areas, and an RN unit manager confirmed that food allergies and preferences should be included in the comprehensive care plan.
Staff failed to protect a resident’s right to privacy in receiving mail when two personal Amazon packages were opened by staff before being given to the resident. The cognitively intact resident, with a history of obesity, type 2 DM, and CHF, reported that staff said they opened the packages because they thought they belonged to the facility. A recreation aide who delivers mail also described a separate incident in which a resident’s package was already open and she refused to deliver it, indicating that opened resident packages had occurred previously, although she could not recall which staff or resident were involved.
Surveyors identified widespread environmental and sanitation deficiencies affecting multiple resident rooms and kitchen areas, including soiled furniture surfaces, missing or damaged baseboards and ceiling tiles, loose or broken toilet handrails, clogged or broken hand-washing sinks, missing or broken soap dispensers, absence of hand soap and trash cans in some restrooms, and stained bedding and bedrails. In shared restroom and tub areas, a broken hot water faucet valve and slow sink drainage were noted. In the kitchen, damaged drywall, dust accumulation above clean utensil racks, an unclean backsplash at the three-compartment sink, significant grease buildup on cooking equipment, and a missing ceiling tile above the dishwashing area were observed and acknowledged by facility leadership.
Surveyors found that staff did not provide required written discharge notices, including bed-hold policy details and notifications to the Ombudsman and State Agency, for two residents who were transferred to the hospital. One resident with severe cognitive impairment and multiple medical conditions was sent to the ER after a fall with a head injury, and another cognitively intact resident with stroke, HTN, DM, and DVT was transferred to a hospital at the request of the resident and family. In both cases, record review showed no documentation of the mandated written discharge/transfer notice, and the Director of Social Work acknowledged that the standard discharge/transfer form was not present in the records.
A resident with severe cognitive impairment, dysphagia, adult failure to thrive, multiple pressure ulcers, and total dependence for ADLs experienced a 5.8% unplanned weight loss in 30 days while not on a physician-prescribed weight-loss regimen. Facility records and MDS data showed poor oral intake, frequent incontinence, unhealed Stage 3 and Stage 4 pressure ulcers, and ongoing nutritional concerns, with the resident receiving a mechanically altered diet and nutritional supplements. Staff, including nursing, wound care, and dietary, acknowledged the resident’s poor intake and that a 5% or greater unplanned weight loss in 30 days is significant and requires intervention, yet the facility did not initiate or complete a Significant Change in Status Assessment (SCSA) in the MDS within the required 14-day timeframe.
Surveyors found that the facility failed to keep care plans current for two residents. One resident with multiple chronic conditions and documented ophthalmology visits, including recommended follow-up, did not have these visits or recommendations reflected in the care plan or progress notes. Another cognitively impaired, functionally dependent resident experienced an unwitnessed fall in her room, was found on the floor with a right elbow skin tear and later diagnosed with right femoral neck and ulnar fractures requiring surgery, yet the care plan was not updated to document the fall event itself, despite existing plans for the skin tear and femur fracture.
A dependent resident with severe cognitive impairment, hemiplegia, and bowel and bladder incontinence did not have any documented ADL care, including toileting, incontinence care, personal hygiene, mobility assistance, turning and repositioning, and hydration, during a night shift. The care plan required checks every two hours, toileting assistance, and pericare after each incontinent episode. CNA task records for that shift were blank for multiple required tasks, and there was no record of care refusal. Staff interviews revealed that the unit was short staffed, that CNAs are responsible for documenting care in the kiosk, and that the nursing supervisor oversees ensuring tasks are completed in the EMR, but no documentation existed to show the required care was provided.
Staff failed to follow physician orders for two residents, resulting in missed fall precautions and improper wound care. One resident with a history of falls and multiple medical conditions had physician orders and a care plan requiring floor mats on both sides of the bed and the bed in the lowest position when in bed, yet an observation found the resident in bed without floor mats, and staff were unaware or unsure of the floor mat requirement. Another resident with severe cognitive impairment and documented Stage 4 and unstageable pressure ulcers had specific wound care orders for the right heel and sacrogluteal areas, including cleansing with wound cleanser and applying zinc oxide to the periwound, but an LPN used normal saline instead of wound cleanser and did not apply zinc oxide to the sacrogluteal periwound, despite the DON confirming that wound cleanser was available and zinc oxide should have been used as ordered.
Facility staff did not ensure a resident received vision care in accordance with professional standards when they failed to arrange and document a recommended annual follow-up with an ophthalmologist. The resident, who had multiple medical conditions including presbyopia and dry eye syndrome, had an ophthalmology report directing a one-year follow-up, but records showed no evidence that this visit occurred and that the resident had not seen an ophthalmologist for several years. During the survey, the resident expressed a desire to see an ophthalmologist, and the DON was informed that the ordered follow-up had been missed.
Staff failed to maintain required back-up tracheostomy supplies at the bedside for a trach-dependent resident with respiratory failure, severe cognitive impairment, and dependence on invasive mechanical ventilation. Facility policy and the resident’s care plan and physician order required an extra size 6 uncuffed trach tube and obturator at the bedside, but during observation no back-up trach or obturator was present. An LPN and the unit manager were unable to locate the back-up trach, and the unit manager produced only gauze, tape, and scissors instead of the ordered trach equipment, while the DON acknowledged that the extra trach and correct size lumen were required to be at the bedside.
An agency RN, without documented post-orientation med pass competency checks, administered an ear medication into a resident’s eye instead of the ordered route, despite there being no active eye-drop orders at that time. The resident, who had multiple comorbidities and significant vision and hearing impairments but intact cognition, immediately reported eye stinging after the drops were given. Facility records showed that while a competency checklist process and med pass audits were described, there was no evidence that this RN’s medication administration skills had been formally observed or validated beyond initial orientation, leading to a significant medication error.
Facility staff did not maintain a consistent and complete record of the consultant pharmacist’s monthly medication review recommendations for a resident with multiple diagnoses, including DM, epilepsy, bipolar disorder, and schizoaffective disorder, who was receiving several psychotropic and insulin medications. Only three pharmacist review documents were found in the paper chart, while reviews for multiple months were missing from both paper and electronic records. An RN unit manager reported that the DON receives the pharmacist’s recommendations by email and distributes them to unit supervisors to place in resident charts, but was unable to locate any additional monthly reviews beyond the three already identified by the surveyor.
Staff failed to consistently honor two residents’ dietary needs and preferences, including one cognitively intact resident with multiple comorbidities and a documented egg allergy whose care plan did not address the allergy or requested double portions, resulting in repeated delivery of egg-containing meals and lack of double portions despite the resident’s complaints and photographic evidence. Another alert, oriented resident with quadriplegia and diabetes, on a regular diet with no known allergies, did not receive lunch until more than an hour after the scheduled delivery time and did not receive a requested cheeseburger from the Always Available Menu, as the tray was not sent with the unit’s meal pass and kitchen staff reported conflicting information about the availability of cheeseburgers and buns.
Facility staff did not consistently offer PM snacks to all residents in accordance with a written policy requiring daily bedtime snacks based on resident needs, preferences, and requests. During a Resident Council meeting, multiple residents reported they were not provided PM snacks, and a resident explained that snacks were prepared only for specific individuals and that others could receive a snack only if the assigned resident refused it. Kitchen observations on two units showed multiple sandwiches labeled with individual resident names, indicating snacks were pre-assigned rather than broadly offered. The Administrator and Executive Director reported they were unaware that residents were not being offered PM snacks.
Staff failed to maintain sanitary food handling and proper hot-holding temperatures, including storing cleaned utensils too close to the floor, lacking test kits to verify sanitizer concentration, and placing single-use coffee cups and lids on the floor under a coffee station. Mashed potatoes were repeatedly held below required hot-holding temperatures on a malfunctioning steam table, utensils were not correctly washed, rinsed, and sanitized in the 3-compartment sink, and the same spatula was used for both raw and cooked hamburgers, resulting in cross-contamination.
Two residents were affected by failures in record accuracy and retention. One resident, with multiple cardiac and chronic conditions, reported missing cash that had been given by a cousin, but review of the unit visitor log showed missing pages for the relevant period, and staff reported they were unaware of the money and described a process for securing valuables that was not documented as used. Another resident, dependent for all ADLs with a G-tube, had physician orders for routine G-tube site dressing changes and daily flush syringe changes, yet the TAR and MAR lacked documentation that a scheduled dressing change and a scheduled flush syringe change were completed as ordered; the DON acknowledged the missing documentation.
A resident with MRSA infection, colostomy complications, multiple wounds, and orders for barrier creams and wound care was on Enhanced Barrier Precautions (EBP) with door signage instructing staff to don gloves, mask, and gown for high-contact care. During incontinent care and hygiene, a CNA washed hands and donned gloves but did not don a gown as required by the facility’s EBP policy, despite PPE being readily available at the door. In a subsequent interview, the CNA acknowledged the resident was on EBP due to a colostomy and wounds and admitted he had simply forgotten to wear the gown, confirming a break in infection control practices.
Surveyors identified that kitchen staff failed to maintain essential equipment in safe working order, including a leaking reach-in refrigerator with a missing light cover, damaged dishwashing components, a broken garbage disposer, a leaking drainpipe, and a ventilation hood missing grease control parts. In addition, a non-operational steam table continued to be used for plating meals, with mashed potatoes repeatedly found at improper hot holding temperatures, despite the Food Service Director being aware that one steam table remained out of service.
Staff did not ensure that all resident rooms and toilet areas were equipped with functional call systems capable of relaying calls directly to staff or a central work area. During an environmental walkthrough of multiple floors, surveyors found that call lights were not working in several resident rooms and toilet rooms, including multiple bed spaces and at least two toilet areas. These deficiencies were identified through observation and interviews and were acknowledged by the facility’s Maintenance Director.
Facility staff did not maintain corridor handrails in safe condition. During an environmental walkthrough, surveyors observed that some handrails on the 1-South unit corridors were not firmly secured to the wall, and a handrail near one room was missing an end cap. These conditions were acknowledged by the Maintenance Director.
Surveyors observed five dead cockroaches under a food preparation sink with a leaking drainpipe in the kitchen cookline area, indicating that staff did not maintain an effective pest control system. The issue was confirmed during an interview with the Food Service Director.
Facility staff did not ensure that a comprehensive care plan review and care plan meeting were conducted at least quarterly for a resident with severe cognitive impairment and multiple diagnoses. Documentation showed that the last care plan meeting was held over 90 days prior, and there was no evidence of timely interdisciplinary team review or revision of the care plan as required.
Two residents with COVID-19 and complex medical histories did not receive the full course of prescribed Paxlovid antiviral therapy as ordered by their physicians. Despite clear orders and care plans, both residents received fewer doses than required, and facility staff, including the DON and Infection Preventionist, were unaware of the missed doses until the issue was brought to their attention during the survey.
A resident receiving IV Vancomycin therapy for bacteremia was found with an unlabeled infusion tubing, contrary to facility policy requiring date, time, and initials on all IV tubing. The LPN present could not identify who hung the IV bag or when, and the issue was confirmed through observation and staff interviews.
A resident with severe cognitive impairment, anemia, and a swallowing disorder was administered crushed Ferrous Sulfate and Potassium Chloride ER tablets by an LPN, despite both medications being labeled 'Do not crush' and without a physician's order. The facility's policy required medications to be given as ordered and per manufacturer instructions, which was not followed.
During a medication pass, an LPN was observed crushing two medications labeled 'Do not crush' for a resident with swallowing issues, resulting in a 40% medication error rate, which exceeded the acceptable threshold. Facility policy required medications to be administered as ordered and per manufacturer specifications, which was not followed.
Staff did not follow posted PPE requirements on the COVID-19 unit during an outbreak, with nursing and dietary staff observed without required face shields and N95 masks, despite clear signage and facility policy.
A resident with severe cognitive impairment and multiple chronic conditions did not receive a physician-ordered COVID-19 vaccine dose. Review of records showed the vaccine was not administered or documented, and the Infection Preventionist was unaware of the order. The facility's process for obtaining consent and ensuring vaccine administration was not followed.
A resident with multiple medical and psychiatric diagnoses was found with self-inflicted wrist lacerations and bloodied bed linens after using a disposable razor. The incident, which involved suicidal ideation and required hospital transfer, was not reported to the State Agency within the required 24-hour timeframe, as facility staff delayed notification until after the weekend.
A resident with ataxia and impaired verbal communication required a communication aid, as recommended by speech therapy, but the care plan did not document this intervention. Staff confirmed the omission, and the care plan only included general communication strategies rather than the specific aid needed for effective communication.
The facility failed to protect residents from physical abuse, leading to a serious incident where two residents with known aggressive behaviors were placed together, resulting in one resident sustaining a stab wound. Additionally, a CNA retaliated against a resident by throwing lemonade and ice, causing scratches on the resident's forehead. These incidents highlight the facility's failure to address known behavioral issues and prevent abuse.
A resident with a history of aggression was placed in a room with another aggressive resident, leading to a physical altercation and injury. The placement decision was made without full awareness of available room options, despite concerns from the DON about the residents' compatibility.
A resident with Schizoaffective Disorder and intact cognitive status was not given written notice of a new roommate assignment, as required. The DON confirmed the lack of written notification, although the resident was verbally informed after returning from a leave of absence.
A resident with multiple diagnoses, including gastrostomy status, experienced a malfunctioning feeding tube that was improperly managed by a nurse who cut the tube after it burst. The nurse failed to document the incident, and the resident was not sent to the ER for replacement until two days later, leading to a deficiency in care.
A resident with a G-tube experienced a malfunction that was not properly managed by the nursing staff. The RN assigned to the resident attempted to unclog the tube, which burst during the process, and then cut the tube to resolve the issue temporarily. This action was not documented, and the resident was not sent to the ER for a replacement until 56 hours later, contrary to facility protocols.
Failure to Maintain Safe Bed Positioning and Shower Supervision Resulting in Resident Head Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent accidents for two residents, resulting in falls with head injuries. For the first resident, who had difficulty walking, muscle weakness, severe anemia, and fibromyalgia, the facility’s own Fall Prevention Program policy required that beds be locked and lowered so that the resident’s feet could be flat on the floor when sitting on the edge of the bed, and that high‑risk residents receive additional interventions such as a low bed. On the evening of readmission, nursing documentation shows the resident was received in bed, alert and verbally responsive. Shortly thereafter, staff were called to the room and found the resident on the floor between two beds, with the resident stating she had jumped out of bed trying to get to her chair. Assessment documented swelling and a superficial open area on the right forehead, and the resident was noted to be alert and oriented to 2–3, with confusion also documented on a fall risk evaluation. Nursing notes further documented that the assigned nurse, upon receiving the resident around 11:03 p.m., checked the resident and noted that the bed was in a high position. The nurse attempted to lower the bed but was unable to do so and went to inform the supervisor about fixing the bed. Around 11:15 p.m., before the issue was resolved, the resident fell from the bed and was found lying on her face, bleeding, with swelling on the right forehead. Staff interviews corroborated that the bed was elevated and not in the lowest position, with the nurse supervisor stating that when she entered the room the bed was at maximum elevation and would not go down. The supervisor also stated that on readmission the nurse should complete a head‑to‑toe assessment and fall assessment and that the bed should be low with items in close proximity for safety, noting that the bed was elevated and things were out of place when she arrived. For the second resident, who had muscle weakness, lack of coordination, left‑side hemiparesis, moderate cognitive impairment, and was dependent on staff for showers, the facility had identified the resident as a moderate fall risk. A nursing note documented that during shower time, the assigned CNA reported that while she and another staff member were assisting the resident by trying to turn him to the side, the resident sustained a fall in the shower room and was later noted with swelling on the right forehead. Subsequent documentation and interviews clarified that two CNAs were assisting the resident in the shower when the incident occurred. One CNA stated that the other CNA turned the resident toward him, but his hands were slippery with soap and he could not stop the resident from hitting his head on the wall, resulting in forehead swelling. The assisting CNA reported that he was on the side of the shower bed near the wall. In a separate interview, the assigned CNA stated that she turned the resident toward the wall where she was standing in the shower room, and that the resident hit his head on the grab bar on the wall when he was trying to pull himself over. When asked why the resident was so close to the wall that he could hit his head, she stated that the resident required two‑person assistance for showers and that the room was too small for two people. She also stated that she did not tell the nurse that the resident fell. The unit manager later stated that both the nurse and the resident told her that he fell in the shower room while staff were giving him a shower, and she could not explain how the resident sustained a hematoma to the head while two staff members were assisting. These events demonstrate that the resident was positioned close enough to the wall and grab bar during assisted showering that he was able to strike his head, and that the assigned CNA did not initially report the fall to the nurse.
Survey Results Not Readily Accessible to Residents and Families
Penalty
Summary
The facility failed to ensure that survey results were placed in a readily accessible area where individuals wishing to examine the results did not have to ask to see them, affecting 65 of 65 sampled residents and/or their families. During an observation of the lobby, the survey results were found stored in a binder labeled “Survey Results” located behind the receptionist’s desk rather than in a publicly accessible location. In a face-to-face interview, the receptionist stated that the survey results binder is always kept behind the desk and is only provided to individuals upon request, confirming that survey results were not freely available for viewing without asking staff.
Failure to Care Plan and Honor Resident’s Egg Allergy and Double-Portion Preference
Penalty
Summary
Facility staff failed to develop and implement a comprehensive, person-centered care plan with measurable objectives and individualized interventions to address a resident’s documented egg allergy and preference for double portions at each meal. The resident was admitted with multiple diagnoses including spinal stenosis, type 2 diabetes with hyperglycemia, discitis, end stage renal disease, and weakness. The medical record included a physician’s order for an LCS/NAS diet with regular texture and thin liquids, and a history and physical that listed allergies to aspirin, codeine, and eggs. A comprehensive MDS showed the resident had intact cognition (BIMS score of 14) and was on a therapeutic diet. However, the comprehensive care plan revised on 01/13/26 did not include the resident’s egg allergy or preference for double portions. During an interview, the cognitively intact resident reported repeated problems with meals over the past weekend, stating that staff kept sending eggs despite the egg allergy and were not providing the requested double portions. The resident stated they had taken photos as evidence and had called the kitchen and spoken with the Director of Kitchen Services several times. The resident’s meal tickets, as shown in photos dated 02/07/26, clearly listed the diet order, egg allergy, dislike of eggs, and a note for double portions/2x meat or protein, along with specific standing orders for breakfast items. Despite this, a photographed breakfast tray showed only a single slice of toast (cut in half) and one slice of breakfast ham, and a photographed lunch tray showed a chef’s salad containing chopped boiled egg. In interviews, the DON explained that care plans are implemented by various clinical staff based on identified focus areas, and a unit manager RN acknowledged that food allergies and preferences should be included in the comprehensive care plan.
Failure to Protect Resident Privacy of Mail and Packages
Penalty
Summary
Facility staff failed to ensure a resident’s mail and packages were kept private and unopened prior to delivery. A cognitively intact resident with obesity, type 2 diabetes, and congestive heart failure reported during a Resident Council meeting that staff had opened two Amazon packages that had been delivered for him. The resident stated staff told him they opened the packages because they believed the packages belonged to the facility, although he could not recall which employee was involved or the dates of delivery. Review of the resident’s rights documented that the resident has the right to have privacy in getting mail. In a subsequent face-to-face interview, a recreation aide reported that she delivers mail to residents and recalled a prior incident in which a resident’s package was already opened when it came to her for delivery. She stated she refused to deliver that opened package and told the person who had it that they needed to deliver it to the resident because it was open, but she could not remember which employee or which resident were involved. These interviews and record reviews showed that at least one resident’s packages were opened by staff before being provided to the resident, contrary to the resident’s right to privacy in receiving mail.
Environmental and Sanitation Deficiencies in Resident Rooms and Kitchen Areas
Penalty
Summary
Facility staff failed to maintain a safe, clean, and sanitary environment in multiple resident rooms and kitchen areas. During an environmental walkthrough, surveyors observed soiled nightstand surfaces, missing or detached baseboards, moisture-damaged ceiling tiles, and broken or loose toilet handrails in several rooms. Additional room-related issues included broken or clogged hand-washing sinks, missing or broken hand-washing soap dispensers, absence of hand-washing soap, a missing trash can in a restroom, a sticky restroom floor, a broken wardrobe cabinet door, a wardrobe in poor repair, a missing pillowcase, and stained bedding and bedrails. In a shared restroom, surveyors found a loose toilet handrail, a broken hot water faucet valve at the hand-washing sink, and slow drainage at the hand-washing sink in the tub room. In the kitchen and food service areas, surveyors identified damaged drywall at the delivery receiving area, dust build-up on ceiling tiles and metal grids above the rack for clean utensils, and an unclean stainless steel backsplash wall cover at the three-compartment dish sink area. They also observed significant grease buildup on cooking equipment and a missing ceiling tile above the dishwashing area. These environmental and maintenance deficiencies were directly observed and acknowledged by the Food Service Director, Maintenance Director, and Environmental Services Director during the survey.
Failure to Provide Required Written Discharge and Bed-Hold Notices on Hospital Transfers
Penalty
Summary
Facility staff failed to provide required written notice of discharge, including bed-hold policy and notification to the Long Term Care Ombudsman and State Agency, for two residents who were transferred to the hospital. The first resident was admitted with multiple diagnoses including difficulty walking, muscle weakness, severe anemia, and fibromyalgia, and had a MDS BIMS score indicating severely impaired cognition. A nursing progress note documented that the resident sustained a fall in her room, was found on the floor with swelling and a superficial open area on the right forehead, and was transferred to the emergency room per NP order for further evaluation and treatment. The care plan documented the fall and the intervention to transfer the resident to the ER. Upon record review, there was no documented evidence that written notification of the resident’s discharge, including bed-hold information and required notices, was provided. The second resident was admitted with diagnoses including stroke with left-sided hemiplegia, hypertension, diabetes mellitus, and deep vein thrombosis, and had an admission MDS BIMS score of 15, indicating intact cognition. A social worker progress note documented that the family requested a hospital transfer, was informed there was no medical reason for transfer but that they had the right to proceed, and that the facility completed the transfer with non-emergency transport to the hospital. A physician order documented that the transfer was per the resident’s request. Record review showed no documented evidence that written notification of the discharge, including bed-hold policy and required notifications, was provided. During an interview, the Director of Social Work acknowledged the absence of the required Notice of Discharge, Transfer or Relocation form in the records and could not explain why it was not filed.
Failure to Complete SCSA After Significant Unplanned Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to complete a Significant Change in Status Assessment (SCSA) in the MDS within 14 days after a resident experienced a significant, unplanned weight loss. The resident had a documented weight decrease from 117.4 lbs to 110.6 lbs over a 30-day period, a 5.8% loss, which met both facility and RAI criteria for significant weight loss requiring comprehensive reassessment and an SCSA. Despite this documented change, there was no evidence that an SCSA was initiated or completed within the required timeframe. The resident had multiple complex medical conditions, including neurocognitive disorder with Lewy bodies, Parkinson’s disease, adult failure to thrive, dysphagia, anorexia, and cognitive communication deficit. The admission and subsequent quarterly MDS assessments documented severely impaired cognitive skills, total dependence for ADLs and mobility, frequent bladder and bowel incontinence, unhealed pressure ulcers (including Stage 3 and Stage 4 ulcers), and weight loss of 5% or more in one month or 10% in six months while not on a physician-prescribed weight-loss regimen. The resident was on a mechanically altered diet, later changed to puree, and was receiving nutritional supplements and an antidepressant. Staff interviews confirmed that the resident had poor oral intake, was non-verbal, required feeding assistance and encouragement to eat, and had multiple pressure ulcers and impaired mobility. The wound nurse and wound NP described the resident as frail, thin, underweight, and at risk for impaired wound healing, and the dietitian stated that unplanned weight loss of 5% or more in 30 days is significant and requires intervention. The RN unit manager stated that significant weight loss should prompt notification of the dietitian and physician and documentation in progress notes but did not recall this resident’s significant weight loss. The DON stated that monitoring weight is the responsibility of all disciplines and deferred to the dietitian regarding whether a 5% weight loss constituted a significant change, yet no SCSA was completed despite the documented significant, unplanned weight loss and associated clinical indicators.
Failure to Update Care Plans After Specialist Visits and Unwitnessed Fall
Penalty
Summary
The deficiency involves the facility’s failure to update and revise comprehensive care plans based on residents’ changing needs and clinical events. For one resident with anemia, polyneuropathy, atherosclerotic heart disease, peripheral vascular disease, HIV, presbyopia, and dry eye syndrome, the care plan did not reflect ophthalmology follow-up visits or recommendations. The resident reported wanting to see an ophthalmologist, and record review showed the resident had been seen by an ophthalmologist multiple times since admission, including a visit with a recommendation for a one-year follow-up. However, the care plan contained no updated documentation that these follow-up visits occurred, and progress notes lacked evidence that the recommended ophthalmology follow-up was completed. For another resident with leukemia, dementia, asthma, and respiratory failure, who required substantial to maximal assistance for mobility and used a wheelchair, the facility did not update the care plan after an unwitnessed fall with injury. Nursing documentation described the resident being found on the floor in her room with a right elbow skin tear and complaints of right-sided pain, followed by orders for an X-ray and transfer to the ER. Hospital records documented a right femoral neck fracture and right ulnar fracture, with subsequent surgical procedures. Although a care plan was initiated for the right elbow skin tear and later for the right femur fracture with surgical site and staples, the care plan was not updated to include that the resident had an unwitnessed fall in her room. The facility’s own documentation policy requires complete, accurate, and timely documentation of residents’ experiences, but the care plan did not reflect this fall event.
Failure to Provide and Document Required ADL Care for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide and document necessary activities of daily living (ADL) care, including toileting, incontinence care, personal hygiene, mobility assistance, turning and repositioning, and hydration, for one dependent resident during a night shift. The resident had multiple significant diagnoses, including Type 2 Diabetes Mellitus, diffuse traumatic brain injury, chronic idiopathic constipation, schizoaffective disorder (depressive type), need for assistance with personal care, flaccid hemiplegia of the left dominant side, contractures, and aphasia. An admission MDS documented severe cognitive impairment with a BIMS score of 07 and coded the resident as dependent on staff for toileting, personal hygiene, bed mobility, and as frequently incontinent of bowel and bladder. The resident’s care plan required staff to check the resident every two hours, assist with toileting as needed, observe incontinence patterns, initiate a toileting schedule if indicated, provide bedpan/bedside commode, ensure loose-fitting clothing, and provide pericare after each incontinent episode. Record review of CNA task documentation for the specified night shift showed no entries indicating that the resident received required ADL care, with multiple tasks left blank, including additional fluids, bed mobility, bowel incontinence, bowel movements, new skin observation, personal hygiene, toileting hygiene, and turning and repositioning. The assignment sheet showed one nursing supervisor, two charge nurses, and five CNAs assigned to the unit that night. A charge nurse stated the resident was total care and dependent on staff for bowel care and that CNAs are responsible for documenting care. One CNA reported the unit was short staffed with only three CNAs on the floor, stated the resident was already soaked at the beginning of the shift, and described changing the bed, providing care, and addressing a later bowel movement, but admitted she did not document the care provided. The RN supervisor stated she oversees CNA documentation and that CNAs often do not complete documentation due to short staffing, but could not recall specific events from that night. There was no documentation in the medical record that the resident refused care, and no documentation to show the resident received toileting assistance, incontinence care, turning and repositioning, or personal hygiene during that night shift as required by the care plan.
Failure to Follow Physician Orders for Fall Precautions and Wound Care
Penalty
Summary
Facility staff failed to follow physician orders and the care plan for a resident with a history of falls and multiple medical conditions, including difficulty walking, muscle weakness, severe anemia, and fibromyalgia. The resident’s care plan, dated 02/04/25, identified a fall with a resulting open area on the right forehead and required floor mats on both sides of the bed when the resident was in bed to minimize fall-related injuries. Physician orders dated 02/07/25 and 02/09/25 further specified fall precautions every shift, including keeping the bed in the lowest position and placing floor mats on both sides of the bed every shift. Despite these orders and documentation that floor mats were in place on 02/09/25, an observation on 01/29/26 at 10:15 AM found the resident in bed with no floor mats on either side. During subsequent interviews, the CNA, RN, and Unit Manager each indicated they were unaware of or unsure about the floor mat requirement, and the DON later confirmed that the orders and care plan required floor mats on both sides of the bed. Facility staff also failed to follow physician orders for wound care for another resident with a history of pressure ulcers and dysphagia, who was severely cognitively impaired, dependent for ADLs, and had one Stage 4 pressure ulcer and one unstageable pressure ulcer. Physician orders directed that the right heel wound be cleansed with wound cleanser, patted dry, treated with betadine, and left open to air twice daily, and that the sacrogluteal wound be cleansed with wound cleanser, patted dry, and treated with collagen, calcium alginate, and zinc oxide paste to the periwound, then covered with a silicone-bordered superabsorbent dressing. A wound assessment documented an unstageable right heel pressure ulcer with 100% eschar and a Stage 4 sacrogluteal pressure ulcer. However, during an observation of wound care, the LPN/Wound Nurse used normal saline instead of wound cleanser on both the right heel and sacrogluteal wounds and did not apply zinc oxide to the periwound of the sacrogluteal wound, although zinc oxide was applied to the buttocks. The LPN/Wound Nurse stated wound cleanser was not available, while the DON later stated that wound cleanser was available and that zinc oxide should have been applied to the sacrogluteal periwound as ordered.
Failure to Ensure Timely Ophthalmology Follow-Up for Vision Care
Penalty
Summary
Facility staff failed to ensure a resident received treatment and care in accordance with professional standards of practice for vision services by not completing a recommended ophthalmology follow-up visit. The resident, admitted on 08/25/2017 with diagnoses including anemia, polyneuropathy, atherosclerotic heart disease, peripheral vascular disease, HIV, presbyopia, and dry eye syndrome of the bilateral lacrimal glands, had an ophthalmologist report dated 12/31/2021 that directed a follow-up visit in one year. Record review of nursing progress notes and ophthalmology consult notes showed no documentation that this one-year follow-up visit occurred, and the resident had not been seen by an ophthalmologist in four years. During the survey, the resident told the surveyor, "I want to see the Ophthalmologist," and the DON was made aware that the resident had missed the one-year follow-up and had not seen the ophthalmologist for four years. The evidence in the record, including the last ophthalmologist visit dated 12/31/2021 and the absence of subsequent documentation, demonstrated that the facility did not arrange or document the required annual ophthalmology follow-up for this resident’s vision care.
Failure to Maintain Required Back-Up Tracheostomy Supplies at Bedside
Penalty
Summary
Facility staff failed to ensure that required back-up tracheostomy supplies were available at the bedside for a tracheostomy-dependent resident. The facility’s “Tracheostomy Care” policy required that a suction machine, suction catheters, correctly sized cannulas, and an ambu bag be easily accessible for immediate emergency care. The resident’s care plan documented that the resident had a size 6 Shiley tracheostomy with a trach collar and directed staff to keep an extra trach tube and obturator at the bedside. The resident’s medical record showed multiple diagnoses including respiratory failure with hypoxia, tracheostomy dependence, aphasia, and seizure disorder, and a quarterly MDS documented that the resident was severely cognitively impaired, dependent for all ADLs, and dependent on respiratory treatments including oxygen therapy, suctioning, trach care, and invasive mechanical ventilation. A physician’s order also specified that a back-up size 6 uncuffed trach be kept at the bedside every shift. During an observation, surveyors noted that there was no back-up size 6 uncuffed tracheostomy tube or obturator at the resident’s bedside. When the assigned LPN was asked where the back-up trach was kept, she searched the bedside area but could not locate it and stated that although she had worked with the resident a few times, it had never come to mind to check for the extra supplies. The unit manager also searched the bedside area without success and then returned with a plastic bag containing only gauze sponges, surgical tape, and bandage scissors, and did not provide information about the back-up trach or its size. The DON acknowledged that extra trach supplies, including the trach and correct size lumen, must always be at the bedside for emergencies, confirming that the required back-up tracheostomy equipment was not in place as ordered and as required by facility policy and the resident’s care plan.
Agency RN Administers Ear Drops into Resident’s Eye Without Documented Med Pass Competency
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in medication administration when a nurse administered an ear medication into a resident’s eye, constituting a significant medication error. The resident involved had multiple medical conditions, including metabolic encephalopathy, dependence on dialysis, type 2 diabetes mellitus, end-stage renal disease, cerebrovascular accident, dysphonia, and required assistance with personal care. The resident also had documented sensory impairments, including blindness in the right eye, deafness in the left ear, moderate hearing difficulty, and severely impaired vision, while remaining cognitively intact with a BIMS score of 15. Physician orders for this resident included Debrox (carbamide peroxide) 6.5% ear drops to be instilled in the right ear twice daily for four days starting on 06/10/25, and later, artificial tears ophthalmic solution to be instilled in the right eye three times daily starting on 06/12/25. Review of the June 2025 MAR showed Debrox was administered on 06/10/25 and 06/11/25, and that there were no eye medication or treatment orders scheduled before 06/12/25 at 9:00 AM. Despite this, on 06/11/25 the assigned RN reported that, after the resident requested medication, she mistakenly instilled an ear drop into the resident’s right eye, after which the resident immediately reported stinging in the eye. The incident was reported internally as a medication given via the wrong route, and facility investigation documents confirmed that the RN had administered an ear drop into the resident’s eye. Interviews with supervisory staff revealed that while the facility had a competency checklist for new and agency nurses and previously conducted medication pass audits, there was no documentation of medication administration competency checks or med pass observations for the RN involved after her initial orientation. The DON confirmed that the nurse was an agency RN and that no additional medication administration training or documented competency assessments were found for her following orientation, indicating a failure to ensure that the nurse possessed and demonstrated the necessary competencies and skills to safely administer medications to the resident.
Missing and Inconsistently Filed Pharmacist Medication Review Recommendations
Penalty
Summary
Facility staff failed to maintain a consistent and accessible location for the consultant pharmacist’s monthly medication review recommendations (MMRs) in the resident’s medical record. For Resident #8, who had intact cognition with a BIMS score of 15 and diagnoses including Type 2 DM, epilepsy, HTN, bipolar disorder, schizoaffective disorder, hepatitis C, and generalized muscle weakness, the surveyor reviewed both paper and electronic records. The resident’s orders included multiple psychotropic and other high‑risk medications, such as Haldol Decanoate given intramuscularly on two separate monthly dates for schizoaffective disorder, Depakote for bipolar disorder with scheduled valproic acid level monitoring, Lantus and Novolog insulins with specific parameters and sliding scale instructions, and ammonia level monitoring. Despite this complex regimen, the surveyor found only three MMR documents in the paper chart: two dated the same day in early January 2025 (one noting an ammonia level of 62 and one stating no irregularities) and one dated in early May 2025 noting a valproic acid level of 41. Further review of the resident’s paper and electronic records showed no documented evidence of the pharmacist’s monthly medication review recommendations for extended periods, specifically from early January 2025 to early May 2025 and from early May 2025 through the end of December 2025. During an interview, the South Unit RN Manager stated that the MMRs should be in each resident’s paper chart, explaining that the DON receives them via email from the pharmacist and then distributes them to unit supervisors to be placed in the charts for physician review and signature. When asked to locate the pharmacist’s recommendations for the missing months in 2025, the RN Manager was only able to produce the three MMRs already identified by the surveyor and made no further comment regarding the absence of the remaining monthly reviews, confirming that the facility had not ensured a consistent location or complete set of pharmacist recommendations for this resident.
Failure to Honor Diet Allergies, Preferences, and Always Available Menu Items
Penalty
Summary
Facility staff failed to ensure that food services accommodated one resident’s documented egg allergy and preference for double portions, and another resident’s meal timing and access to items on the Always Available Menu. One resident was admitted with multiple diagnoses including spinal stenosis, type 2 diabetes with hyperglycemia, discitis, end stage renal disease, and weakness. The resident’s medical record included a physician’s order for an LCS/NAS diet with regular texture and thin liquids, and a History and Physical documenting allergies to aspirin, codeine, and eggs. A comprehensive MDS showed intact cognition and a therapeutic diet, but the comprehensive care plan, revised on a later date, did not address the resident’s egg allergy or preference for double portions. During an interview, this resident reported that over the past weekend the facility repeatedly sent eggs on meal trays despite the documented egg allergy and did not provide the requested double portions. The resident stated they had taken pictures as evidence and had personally called the kitchen and spoken with the Director of Kitchen Services on several occasions about these issues. In a subsequent interview, the Food Services Manager described a process in which 14 staff, including a supervisor or assistant, check meal trays before they are sent to the units, and noted that more than 70 residents receive some type of double portion. After reviewing the resident’s photos, the Food Services Manager acknowledged the issue and was unable to explain how the errors occurred. Another resident, with diagnoses including cervical spinal stenosis, quadriplegia, central cord syndrome, type 2 diabetes with peripheral angiopathy, major depressive disorder, and hypertension, was assessed as alert, oriented, able to communicate needs, and requiring assistance with ADLs. This resident had a physician’s order for a regular diet with regular texture and thin liquids and no documented food allergies, and had documented multiple food preferences and a request for access to a regular diet for greater choices. On one observation day, the resident complained in the early afternoon that lunch had not yet been received, and the tray was not delivered until approximately 1:55 PM, more than an hour after the scheduled delivery time of 12:45 PM. The resident also reported that a cheeseburger ordered from the Always Available Menu the previous day was not received. Staff interviews revealed that the cheeseburger tray was not sent with the unit’s meal trays and had to be obtained separately, and that although cheeseburgers were available in the kitchen, buns were not, leading to conflicting information given to staff that cheeseburgers and hotdogs were not available, despite the item being listed on the Always Available Menu.
Failure to Offer PM Snacks According to Resident Needs and Preferences
Penalty
Summary
Facility staff failed to ensure residents received PM snacks in accordance with the facility’s policy and residents’ needs, preferences, and requests. A policy titled “Offering/Serving Bedtime Snacks” dated 08/15/25 directed nursing staff to offer bedtime snacks to residents daily based on their needs and preferences. During a Resident Council meeting on 01/14/26 with multiple residents from different units, residents reported that they were not provided with PM snacks. One resident stated that PM snacks were prepared only for specific residents, with individual names placed on the snacks, and that he could only receive a PM snack if the resident to whom it was assigned refused it. Observations of the kitchens on Unit 1 South and 3 South on 01/15/26 showed multiple sandwiches labeled with residents’ names, supporting the report that snacks were pre-assigned rather than offered to all residents. In a face-to-face interview on 01/15/26, the Administrator and Executive Director stated they were not aware that residents were not being offered PM snacks. These findings demonstrate that, despite having a written policy requiring daily offering of bedtime snacks according to resident needs and preferences, the facility did not consistently offer PM snacks to all residents and instead limited snack availability to certain residents whose names were on pre-prepared items.
Failure to Maintain Sanitary Food Handling and Proper Hot-Holding Temperatures
Penalty
Summary
Facility staff failed to prepare and distribute food under sanitary conditions in the kitchen. During a walkthrough, cleaned and sanitized food-contact utensils were stored on a rack without the required 6-inch clearance from the floor in the manual dishwashing area, and there was no proper test kit available to monitor the concentration of sanitizing solution in the 3-compartment sink or in sanitizing buckets. Single-use coffee cups and lids were also observed stored on the floor under the coffee-making station. These conditions were observed and acknowledged by the Food Service Director. On subsequent kitchen observations, mashed potatoes were repeatedly held at improper hot-holding temperatures, with recorded temperatures of 134°F and 132°F on a broken steam table on one day, and 123°F and 120°F on another day. Kitchen utensils were not properly washed, rinsed, and sanitized in the 3-compartment sink, and the same spatula was used to handle both raw and cooked hamburgers on the griddle, creating cross-contamination. These additional unsanitary food handling and temperature control issues were also observed and acknowledged by the Food Service Director.
Failure to Maintain Accurate Visitor Logs and G-Tube Documentation
Penalty
Summary
Facility staff failed to safeguard resident-identifiable information and maintain accurate records by not ensuring the integrity and retention of the visitor logbook for one resident. A resident admitted with diabetes mellitus, myocardial infarction, fluid overload, hypertension, osteoarthritis, and congestive heart failure reported that $200 was missing from his room while residing on the 2 South unit. The resident stated that his cousin had visited and given him the money. When surveyors reviewed the 2 South visitor logbook for the period when the money was allegedly brought in, they found that pages covering dates from 04/01/2025 through 04/29/2025 were missing. Staff assigned to the resident on the date the money was reported missing stated they were unaware the resident had $200 and described that the process for securing resident valuables would be to notify the RN to place valuables in a safe. The Director of Nursing acknowledged that the visitor logbook was missing pages for that period and that she was unable to locate them. Facility staff also failed to maintain complete and accurate medical records for another resident with multiple diagnoses including stroke, dysphagia, gastrostomy tube, dementia, and seizure disorder. An Annual MDS documented that this resident had a severely impaired BIMS score, was totally dependent on staff for all ADLs and transfers, and had a G-tube for feedings. Physician orders directed that the G-tube site dressing be changed every night shift in the morning and that the enteral feed flush syringe be changed every morning every 24 hours. Review of the Treatment Administration Record for February showed no documented evidence that the G-tube site dressing change was completed on a specified morning as ordered, and review of the Medication Administration Record for the same month showed no documented evidence that the G-tube flush syringe was changed on another specified morning as ordered. The Director of Nursing acknowledged the lack of documentation and stated she could not vouch for what was not done and could only provide education on proper documentation.
Failure to Follow Enhanced Barrier Precautions During Incontinent Care
Penalty
Summary
The deficiency involves staff failure to follow the facility’s Enhanced Barrier Precautions (EBP) policy when providing high-contact care to a resident on EBP. The facility’s EBP policy, revised on 06/26/25, defines EBP as an infection control intervention using targeted gown and glove use during high-contact resident care activities, including providing hygiene and changing briefs. The policy states that all staff are trained on EBP upon hire and at least annually and are expected to comply, and that PPE for EBP is required during high-contact care activities. Signage on the resident’s door indicated the resident was on EBP and directed staff performing any high-contact care activity to don gloves, a mask, and a gown before entering the room. A storage bag with gloves, masks, and gowns was hanging on the resident’s door. The resident involved was admitted with multiple diagnoses, including MRSA infection, complications of colostomy, hidradenitis suppurativa, protein calorie malnutrition, and a need for assistance with personal care, and had multiple physician orders for barrier creams, colostomy care, urinary fistula care, and wound care to the groin areas. During an observation, the resident requested a brief change, and a CNA responded, washed hands, and donned gloves but did not don a gown before entering the room and performing incontinent care and applying cream. After completing care, the CNA removed gloves and washed hands before exiting. In a face-to-face interview, the CNA acknowledged the resident was on EBP due to a colostomy and wounds and stated he did not know why he had not put on a gown, saying he “just forgot,” thereby confirming noncompliance with the facility’s EBP policy during a high-contact care activity.
Failure to Maintain Kitchen Equipment and Safe Hot Holding Temperatures
Penalty
Summary
Facility staff failed to maintain essential kitchen equipment in safe, working condition, as evidenced by multiple deficiencies observed during surveyor walkthroughs. On the initial kitchen survey, the reach-in refrigerator next to the ice machine was leaking condensate water inside the food storage chamber and was missing a light bulb cover. In the dishwashing area, the spray hose storage hook and the atmospheric backflow preventer valve cover were in poor repair. Additional observations included a broken garbage disposer attached under a food preparation sink, a leaking drainpipe under the food preparation sink at the cookline, and a kitchen ventilation exhaust hood missing a grease trap pan and one grease filter. These conditions were acknowledged by the Food Service Director during interviews. On subsequent kitchen surveys, the steam table used for hot holding food was found to be non-operational while staff continued to use it for plating resident meals. During one visit, mashed potatoes held on the broken steam table were measured at 134°F and 132°F, and on a later visit, mashed potatoes were again found at improper hot holding temperatures of 123°F and 120°F. The Food Service Director reported that one steam table had gone out of operation the previous day and that only one of the steam tables had been repaired while the other remained non-functional, yet the non-operational unit continued to be used for meal service. No specific residents were individually identified in the report, and no resident medical histories or conditions were described.
Nonfunctional Call Systems in Multiple Resident Rooms and Toilets
Penalty
Summary
Facility staff failed to ensure that each resident’s bathroom and bathing area was equipped with a working call system capable of relaying calls directly to staff or a centralized work area from resident bedside and toilet facilities. During an environmental walkthrough of the 1st, 2nd, and 3rd floors on January 21, 2026, between approximately 10:30 AM and 2:00 PM, surveyors identified multiple nonfunctional resident call lights out of 52 surveyed rooms. Specifically, call lights were not functional in rooms [ROOM NUMBER]-A, 134-B, 132 toilet room, 152-A, 122-A and B, 106-A, and the toilet room in 111. These findings were based on direct observation and interviews and were acknowledged by the Maintenance Director (Employee #19) during a face-to-face interview on January 21, 2026, at approximately 2:00 PM. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
Unsecured Corridor Handrails and Missing End Cap
Penalty
Summary
Facility staff failed to ensure that corridor handrails were firmly secured to the walls as required. During an environmental walkthrough of the facility on January 21, 2026, between 10:30 AM and 2:00 PM, surveyors observed that some handrails in the 1-South unit corridors were not firmly attached to the adjacent wall. Additionally, the handrail near room [ROOM NUMBER] was missing an end cap. These environmental deficiencies were confirmed by the Maintenance Director (Employee #19) at approximately 1:45 PM on the same day.
Failure to Maintain Effective Pest Control in Kitchen Cookline Area
Penalty
Summary
Facility staff failed to maintain an efficient pest control system in the kitchen cookline area. During the survey, five dead cockroaches were observed under a food preparation sink that had a leaking drainpipe in the cookline. These observations demonstrated that the facility did not effectively prevent or address the presence of pests in this food service area. The deficiency was identified based on direct observation and staff interview, with the Food Service Director acknowledging the presence of the dead cockroaches under the food preparation sink in the kitchen cookline.
Failure to Conduct Timely Quarterly Care Plan Review
Penalty
Summary
Facility staff failed to ensure that a comprehensive care plan review and care plan meeting were conducted at least quarterly for one resident with multiple diagnoses, including schizophrenia, hypertension, and major depressive disorder. The resident, who has a legal guardian and is coded as DNR, was admitted to the facility and had a documented severe cognitive impairment based on a BIMS score of 00. The last documented care plan meeting for this resident occurred over 90 days prior to the review, and there was no evidence that the interdisciplinary team (IDT) reviewed or revised the care plan within seven days of the most recent quarterly MDS assessment. Record review and staff interviews confirmed the absence of required quarterly care plan meetings and timely IDT review for the resident. The Social Services Director acknowledged that the last care plan meeting was held more than 90 days ago and could not provide a reason for the delay. Documentation did not show that the care plan was reviewed or updated as required by regulation, resulting in a deficiency related to care plan management for this resident.
Failure to Administer Prescribed Antiviral Medication as Ordered
Penalty
Summary
Facility staff failed to ensure that two residents received their prescribed Paxlovid antiviral medication for the full duration as ordered by their physicians. Both residents had multiple significant diagnoses, including epilepsy, cerebral infarction, and malignant neoplasm of the liver, and were diagnosed with COVID-19 during their stay. Physician orders and care plans clearly directed that each resident was to receive Paxlovid twice daily for five days, totaling ten doses per resident. Medical record reviews and Medication Administration Records (MAR) revealed that the residents did not receive the full course of medication as ordered. One resident received only six out of ten doses over three days, while the other received seven out of ten doses over three and a half days. Documentation showed repeated notes indicating that the pharmacy was called regarding the medication, but there was no evidence that the orders were adjusted or that the full course was administered as prescribed. Staff interviews confirmed that facility leadership, including the DON and Infection Preventionist, were unaware that the residents had not received the complete course of Paxlovid. The deficiency was further substantiated by a complaint received by the State Agency, which reported that patients had not received medication for several days and described medication errors and staffing issues. The failure to administer medications as ordered was not identified or addressed by facility staff prior to the survey.
Failure to Label IV Tubing During Antibiotic Administration
Penalty
Summary
Facility staff failed to minimize risks for a resident receiving intravenous (IV) therapy by not labeling and dating the IV infusion tubing as required by facility policy. The policy specified that all IV tubing must be labeled with the date, time, and initials. During an observation, a resident with a midline IV site in the left upper arm was found connected to infusion tubing and an empty IV Vancomycin medication bag, but the tubing was not labeled with the required information. At the time of observation, the LPN present was unable to identify who had hung the IV bag or when it was done. The resident involved had multiple diagnoses, including epilepsy, cerebral infarction, and a benign neoplasm of the cerebral meninges, and was receiving Vancomycin IV therapy for bacteremia as ordered by a physician. Documentation showed that the midline was placed and the resident tolerated the procedure well, with no adverse reactions noted. However, the failure to label the IV tubing was directly observed and confirmed by staff interviews, indicating non-compliance with established protocols for safe IV administration.
Failure to Follow Medication Administration Protocols for Resident with Swallowing Disorder
Penalty
Summary
Facility staff failed to demonstrate competent nursing skills in the administration of medications for one resident with multiple diagnoses, including schizophrenia, hypertension, major depressive disorder, and anemia. The resident had severe cognitive impairment, a swallowing disorder, and was on a mechanically altered diet. Physician orders specified oral administration of Ferrous Sulfate and Potassium Chloride ER tablets, both of which were labeled 'Do not crush.' During a medication pass, an LPN was observed crushing these medications and mixing them with applesauce for administration, despite the clear labeling and absence of a physician's order to do so. The LPN explained that all medications were being crushed for the resident due to her swallowing issues and thickened liquid diet. However, the medical record did not contain any current physician order authorizing the crushing of these medications. The facility's policy required medications to be administered as ordered and in accordance with manufacturer specifications, which was not followed in this instance. The deficiency was confirmed through observation, record review, and staff interviews.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Crushing
Penalty
Summary
Facility staff failed to maintain a medication error rate below 5% during a medication administration pass on unit 3 south. Out of five observed medication administration opportunities, two errors were identified, resulting in a 40% error rate. Specifically, an LPN was observed crushing two medications that were clearly labeled by the manufacturer as 'Do not crush' on their blister packets. The LPN explained that all medications for the resident in question were being crushed and administered in applesauce due to the resident's swallowing difficulties and requirement for a thickened liquid diet. The facility's policy required medications to be administered as ordered and in accordance with manufacturer specifications, which was not followed in these instances.
Failure to Enforce PPE Requirements on COVID-19 Unit
Penalty
Summary
Facility staff failed to implement infection control policies and procedures as required by the facility's Infection Prevention and Control Program. During a facility tour, two nursing staff were observed on the designated COVID-19 unit not wearing the required face shields (eye protection), despite signage at the entrance specifying that both a face shield and mask were required at all times. The Infection Preventionist present during the observation acknowledged that these staff members did not follow the posted PPE requirements. In a subsequent observation, after new signage was posted requiring N95 masks and face shields for staff on the COVID-19 unit, a dietary staff member was observed not wearing either the N95 mask or face shield. This was again acknowledged by the Infection Preventionist. These observations occurred while the facility was experiencing a COVID-19 outbreak with 16 residents testing positive, and demonstrate that staff did not consistently adhere to posted PPE requirements as outlined in the facility's infection control program.
Failure to Administer COVID-19 Vaccine as Ordered
Penalty
Summary
Facility staff failed to administer the COVID-19 immunization as ordered for one resident with multiple diagnoses, including Type 2 Diabetes Mellitus, Congestive Heart Failure, and Alzheimer's Disease. The resident was admitted with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 04. The resident's medical record showed that the last COVID-19 booster was received in September 2022, and a physician's order was placed on February 19, 2025, for administration of the Comirnaty COVID-19 vaccine. However, review of the Medication Administration Record (MAR) for that date showed no documentation that the vaccine was administered. Staff interviews revealed that the Infection Preventionist was unaware of the vaccine order for the resident and did not have documentation of its administration. The facility's process requires obtaining consent from the resident or responsible party before administering the vaccine, but there was no evidence that this process was completed or that the vaccine was given as ordered. The deficiency was identified through record review and staff interviews, confirming a failure to follow the facility's Infection Prevention and Control Program and physician's orders regarding COVID-19 immunization.
Failure to Timely Report Resident Self-Harm Incident to State Agency
Penalty
Summary
Facility staff failed to notify the State Agency within the required 24-hour timeframe after an incident involving a resident who was found with self-inflicted lacerations on the right wrist using a disposable shaving razor. The resident, who had a history of Paranoid Personality Disorder, TIA, cerebral infarction, adult failure to thrive, and hereditary ataxia, was discovered with bloodied bed linens and expressed suicidal ideation. The incident was documented in the medical record, and the resident was assessed by a licensed nurse and subsequently transferred to the hospital for further evaluation. Despite the facility's policy requiring immediate or timely reporting of alleged abuse, neglect, or injury of unknown origin, the incident was not reported to the State Agency until after the required timeframe had elapsed. Staff interviews confirmed that the incident occurred before the resident's transfer to the hospital, but the report was not submitted until the following business day when facility leadership returned, indicating a lapse in timely notification as required by regulation.
Failure to Document Communication Aid in Care Plan
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered care plan that included documentation of a communication aid for a resident with multiple diagnoses, including ataxia, which impaired verbal communication. The resident was cognitively intact but had difficulty expressing himself verbally, requiring the use of a communication aid consisting of laminated pages with words and letters, as recommended by the speech therapist. The speech therapy discharge summary indicated that the resident's communicative effectiveness improved with the use of trained strategies and aids. Despite these recommendations and the resident's ongoing need for the communication aid, the care plan only addressed general communication strategies such as identifying oneself, making eye contact, and using simple sentences, but did not document the use of the specific communication aid. Staff interviews confirmed that the care plan lacked this critical intervention, and there was no documented evidence that the communication aid was included in the resident's care plan to support his ability to communicate.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, resulting in a serious incident involving two residents with known aggressive behaviors. Resident #2, who had a history of physical aggression, was readmitted to the facility and placed in a room with Resident #1, who also had a history of aggressive behavior and sexual misconduct. Despite concerns raised by staff about the compatibility of these two residents as roommates, the decision was made by the administration to place them together due to bed availability. This decision led to a physical altercation where Resident #2 sustained a stab wound to his left leg, requiring medical attention. In another incident, the facility failed to protect Resident #4 from physical abuse by a staff member. Resident #4, who had a history of behavioral issues and cognitive impairment, was involved in an altercation with Employee #9, a CNA. The altercation began when Resident #4 allegedly threw a cup of lemonade at the CNA, who then retaliated by throwing lemonade and ice back at the resident. This resulted in Resident #4 sustaining scratches on his forehead. The CNA admitted to throwing the lemonade but denied hitting the resident. These incidents highlight the facility's failure to ensure the safety and well-being of its residents by not adequately addressing known behavioral issues and failing to prevent physical abuse. The lack of proper monitoring and inappropriate room assignments contributed to the harm experienced by the residents involved.
Inadequate Room Assignment Leads to Resident Altercation
Penalty
Summary
The facility staff failed to ensure reasonable accommodations for room assignments, which compromised the health and safety of residents. Resident #2, with a history of physically aggressive behavior, was placed in a room with Resident #1, who also had a known history of aggression. This decision was made despite the Director of Nursing's (DON) concerns about the compatibility of the two residents due to their unpredictable behaviors. The placement was based on the availability of beds as informed by the Admissions Department, which did not notify the DON of a more suitable room that was available. Resident #2 had been readmitted to the facility from a psychiatric hospital and had previously exhibited aggressive behavior towards other residents. Upon his return, he refused a complete physical assessment and other admission procedures. Despite these red flags, he was placed in a room with Resident #1, who had a care plan indicating recent aggressive behavior. The decision to place Resident #2 in this room was made temporarily by the DON, who was aware of the potential risks but was not informed of other available options. The situation escalated when Resident #2 and Resident #1 were involved in a physical altercation, resulting in Resident #2 sustaining a stab wound that required medical intervention. The altercation occurred shortly after Resident #2's readmission, highlighting the failure of the facility to provide a safe and suitable room assignment. The incident was severe enough to involve police and emergency medical services, underscoring the inadequacy of the room placement decision and the lack of communication within the facility regarding available accommodations.
Failure to Provide Written Notice of Roommate Change
Penalty
Summary
The facility staff failed to provide a resident with written notice that a new roommate had been assigned to his room. This deficiency was identified for one of the nine sampled residents. The resident, who was admitted with multiple diagnoses including Schizoaffective Disorder, Anxiety, and Depression, had a cognitive status that was intact as per a recent assessment. The resident's care plan documented incidents of physical and verbal aggression, and he was on anti-psychotic medications. Despite these considerations, there was no documented evidence that the resident received written notification about the new roommate. During an interview, the Director of Nursing (DON) confirmed that the resident was not notified in writing about the new roommate. Instead, the resident was verbally informed after returning from a leave of absence. The leave of absence sign-out sheet indicated that the resident left the facility and returned later the same day, but the written notification requirement was not met, leading to the deficiency finding.
Failure to Appropriately Manage G-Tube Malfunction
Penalty
Summary
The facility failed to provide appropriate treatment and management for a resident with a malfunctioning enteral feeding tube. The resident, who had multiple diagnoses including gastrostomy status, type 2 diabetes mellitus, cerebral infarction, and dementia, was dependent on tube feeding as their sole nutrition source. On a specific day, a registered nurse discovered that the resident's gastrostomy tube was clogged and attempted to unclog it using a syringe of water, which resulted in the tube bursting. The nurse then cut the tube below the burst area, which temporarily resolved the issue, allowing the nurse to administer medications and feeding. Despite the temporary fix, the nurse failed to document the malfunction or the actions taken to address it. The resident's medical record did not reflect any issues with the tube until two days later when the resident was finally sent to the emergency room for a tube replacement. During this period, the resident continued to receive feedings and medications through the altered tube, which was not the standard practice for managing such malfunctions. Interviews with facility staff revealed that cutting a resident's gastrostomy tube was not the facility's protocol for managing clogs or malfunctions. The assistant director of nursing confirmed that the resident should have been sent to the emergency room immediately when the malfunction was first identified. The lack of documentation and delay in appropriate medical intervention led to a deficiency in the care provided to the resident.
Failure to Properly Manage G-Tube Malfunction
Penalty
Summary
The licensed nursing staff at the facility failed to demonstrate appropriate competencies and skill sets in managing a gastrostomy tube (G-tube) for a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including Gastrostomy Status, Type 2 Diabetes Mellitus, Cerebral Infarction, and Dementia, was dependent on tube feeding as their sole nutrition source. On 06/16/24, the assigned RN, Employee #12, discovered that the resident's G-tube was clogged and attempted to unclog it with a colleague, Employee #13. During the process, the tube burst, and Employee #12 cut the tube below the burst point, which temporarily resolved the issue. However, this action was not documented, and the resident was not sent to the ER for tube replacement until 06/18/24, 56 hours later. The report highlights that the facility's protocol for managing G-tube malfunctions was not followed. Employee #12 did not document the malfunction or the intervention taken, which included cutting the tube, nor did they immediately send the resident to the ER for a replacement. The Assistant Director of Nursing (ADON), Employee #14, confirmed that cutting a G-tube is not the standard practice for managing clogs or malfunctions and that the resident should have been sent to the ER immediately on the day the malfunction was discovered. The deficiency was further compounded by the lack of documentation and communication regarding the G-tube malfunction. The resident's medical records did not reflect any issues with the G-tube until 06/18/24, when the resident was finally sent to the ER. This delay in appropriate intervention and documentation led to a complaint being filed with the State Agency, highlighting the failure of the nursing staff to ensure the safety and well-being of the resident.
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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