Deanwood Rehabilitation And Wellness Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 5000 Nannie Helen Burroughs Ave. Ne, Washington, District Of Columbia 20019
- CMS Provider Number
- 095019
- Inspections on file
- 26
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Deanwood Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
A resident with COPD and chronic respiratory failure, on continuous O2 via nasal cannula, had a care plan requiring an escort when using the stairs. Surveyors observed the resident alone in a stairwell, short of breath, descending the stairs while using 3 L O2 and managing a wheeled E-tank, after a staff member had allowed access to the coded stairwell. The administrator acknowledged the resident should have had someone with him on the stairs, demonstrating a failure to provide adequate supervision and assistance to prevent accidents under F689.
Staff failed to follow infection prevention and control practices, including not performing hand hygiene or donning required PPE before entering the room of a resident on contact/droplet precautions for conjunctivitis, and not performing hand hygiene while distributing meal trays. One alcohol-based hand rub station near the nurse’s station was inoperable, and a staff restroom had a broken soap dispenser, leading staff to use resident bath/shampoo product instead of appropriate hand soap for hand hygiene.
Staff failed to accurately code MDS assessments for two residents, resulting in incorrect documentation of rejection of care and wandering behaviors. One resident with CVA and other comorbidities refused lab work and was care planned for noncompliance, yet the admission MDS was coded to show no rejection of care despite documentation during the 7‑day lookback period. Another resident with CKD, Alzheimer’s disease, and other conditions was coded on a Significant Change MDS as exhibiting wandering 4–6 days and being at significant risk, even though observations showed the resident was non‑ambulatory in a Geri chair with close supervision and chart reviews revealed no wandering behaviors; the social worker later acknowledged coding based on past history rather than current behavior.
A resident with COPD, chronic respiratory failure with hypoxia, and hypertension had a care plan requiring an escort when using the stairs and a physician order for continuous O2 via nasal cannula. Despite this, the resident, who experienced SOB with exertion and at rest and used oxygen therapy, was observed alone in a stairwell, noticeably short of breath, carrying a portable O2 E-tank in a wheeled caddy. The stairwell required a 4-digit code for access, and the resident reported that staff had let him down because he preferred stairs over elevators. The Administrator confirmed the resident should have had someone with him when using the stairs, showing the care-planned escort intervention was not implemented.
Staff failed to ensure continuous oxygen therapy for a resident with COPD and chronic respiratory failure who had orders and a care plan for continuous O2 at 2–3 L/min via nasal cannula. The cognitively intact resident, who experienced SOB with exertion and at rest, was observed alone in a stairwell, noticeably short of breath, carrying a portable E-tank in a wheeled caddy. The tank gauge was in the red "0 refill" zone, indicating it was empty, and the unit manager confirmed the tank was empty and that the assigned nurse was responsible for checking O2 tanks before residents left the unit.
Two staff members delivered and distributed resident meal trays on a unit without performing required hand hygiene, despite regulations requiring hand decontamination before meal delivery and when entering or exiting rooms or common areas. During the same observation, the alcohol-based hand rub dispenser outside a room was found to be nonfunctional due to a broken handle, leaving staff without a working sanitizer at that location while handling meal trays.
Facility records showed that on a day when Immediate Jeopardy was identified, the facility did not meet the State-required minimum average of 4.1 hours of direct nursing care per resident per day, instead providing 3.9 hours with a census of 273 residents. In an interview, the staffing coordinator acknowledged awareness of the 4.1-hour requirement and reported that efforts were being made to meet that standard.
Staff inaccurately documented that two residents received scheduled showers with skin checks when, according to the residents and the assigned RN, they had refused showers and instead received bed baths. Documentation on the TAR and CNA records showed showers as completed and refusals recorded, despite residents’ statements that no showers occurred. In a separate case, a resident with COPD and chronic respiratory failure, who had active orders and care plan interventions for continuous O2 via nasal cannula and was coded on the MDS as using oxygen therapy, was documented on a Safe Smoker Assessment as having no continuous or PRN oxygen order and as a safe smoker who preferred cigarettes, even though the resident reported not having smoked for many years.
Surveyors identified widespread housekeeping deficiencies, including dust buildup, dirty and sticky floors, soiled toilets, stained privacy curtains, dirty trash cans, and a strong urine odor in several areas. These issues were acknowledged by facility staff and affected multiple resident rooms and common areas.
Staff did not maintain an effective pest control program, as flies were observed in three resident rooms. In one case, a soiled trash can with a dark substance attracted flies, while in another, flies were found near human waste under a portable toilet. Additional flies were seen on a privacy curtain and pillow in a third room. These deficiencies were confirmed by staff interviews and direct observation.
Facility staff did not ensure that a resident received the correct prescribed dose of Trazodone for five days, as only 25 mg tablets were available when a 50 mg dose was ordered. Documentation indicated the 50 mg dose was given, but there was no confirmation that the correct amount was administered. The resident, with a history of depression and dementia, experienced lethargy and was sent to the ER, though no new findings were reported.
A licensed nurse altered a resident's Trazodone medication order label without notifying the physician, resulting in the administration of a dosage not prescribed. The resident had multiple diagnoses, including dementia and depression, and was cognitively impaired. Facility staff could not identify who made the change, and the ADON stated that nurses could use their own judgment for non-narcotic medications, contrary to facility policy and accepted nursing standards.
A resident with severe cognitive impairment and depression was prescribed Trazodone 50 mg at bedtime, but only 25 mg half-tablets were available for administration. Staff documented giving the full 50 mg dose on the MAR, but it could not be confirmed whether the correct amount was actually administered, as only half-tablets were present and staff could not verify the dosing process.
A resident with moderate cognitive impairment expressed concern about her non-functioning television, and an RN interrupted her to dispute her account, leading the resident to feel disrespected. The incident occurred during a period of cable service disruption related to a provider change.
A resident with multiple medical conditions and moderate cognitive impairment experienced room temperatures below the required 71°F to 81°F range for at least a week, despite reporting the issue to staff. Facility leadership was unaware of the problem, and there was no consistent documentation or use of the electronic maintenance request system to track or address temperature concerns.
Failure to Supervise Resident Using Stairwell with Oxygen
Penalty
Summary
Facility staff failed to ensure adequate supervision and assistance to prevent accidents for Resident #4, who had COPD, chronic respiratory failure with hypoxia, and hypertension, and was receiving 2–3 L/min oxygen via nasal cannula per physician order. The resident’s care plan, revised on 10/29/25, specified that he was to use the stairs when going down and coming back in, with an escort. A Quarterly MDS showed he had intact cognition (BIMS 15), no functional impairment in range of motion, was independent with transfers and walking 150 feet, and used oxygen therapy. On 01/30/26 at 3:47 PM, surveyors observed the resident alone in the 2-north stairwell, going down the stairs, noticeably short of breath, with oxygen at 3 L via nasal cannula, and carrying an E-tank oxygen cylinder in a wheeled caddy. The resident stated he did not like taking elevators and therefore used the stairs, and reported that a staff member had let him down to the stairwell, which required manual entry of a 4-digit code from the units. In a face-to-face interview shortly thereafter, the Administrator acknowledged that the resident used the stairwell due to claustrophobia and stated that he should have someone with him when using the stairs. The evidence showed that serious harm was likely to occur as the resident was short of breath, alone in the stairwell, and carrying an oxygen tank, demonstrating that facility staff did not provide adequate supervision as required under 42 CFR 483.25, F689.
Removal Plan
- Resident #4 was immediately assessed by a licensed nurse, including a head-to-toe assessment and fall risk assessment, with documentation entered in the electronic health record.
- Resident #4 received education by a licensed nurse regarding stair safety, safety with oxygen tank/portable oxygen use, oxygen tubing safety, fall precautions, and leave-of-absence (LOA) precautions.
- The Nurse Educator/designee initiated staff education for all staff on stair safety and resident supervision, including documentation of escort refusal; staff not yet educated will receive education when they come on shift.
- Resident #4's care plan was updated by a licensed nurse to reflect non-compliance with staff escort while using the stairwell.
- The stairwell entry code was changed and education was provided to all staff regarding the new code.
Failure to Implement Hand Hygiene and Contact Precaution Practices
Penalty
Summary
Facility staff failed to implement infection prevention and control practices related to contact and droplet precautions, hand hygiene, and availability of appropriate hand hygiene supplies. A resident with end stage renal disease, diastolic CHF, and moderate cognitive impairment was placed on contact isolation for bacterial conjunctivitis of the left eye, with a posted sign requiring droplet/contact precautions including hand hygiene on entry and exit, and use of gown, N95 respirator, eye protection, and gloves. While the unit manager stood outside this resident’s room and discussed the isolation status, a staff member was observed entering the room without performing hand hygiene or donning any PPE, later stating she was only going in to replace the resident’s water. Additional observations showed that staff did not consistently perform hand hygiene and that required hand hygiene equipment was not functional or appropriate. During a dining observation, two staff members distributed and delivered meal trays without performing hand hygiene, and an alcohol-based hand rub station near the nurse’s station was found to be nonfunctional due to a broken handle. In a staff restroom on another unit, the wall-mounted hand soap dispenser was broken and nonfunctional, and staff were instead using a bottle of Sterex Medical Hospital bath and shampoo at the sink for handwashing. The infection preventionist confirmed that this product is used to bathe residents and is not acceptable for staff hand hygiene and was unsure how long the dispenser had been broken or how long staff had been using the shampoo for handwashing.
Inaccurate MDS Coding for Rejection of Care and Wandering Behaviors
Penalty
Summary
Facility staff failed to ensure accurate coding of Minimum Data Set (MDS) assessments for two residents, specifically related to rejection of care and wandering behaviors. One resident with multiple diagnoses including CVA, hemiplegia, COPD, and muscle disease was documented on 12/24/25 as alert, oriented, verbally responsive, and refusing lab work, with the MD and representative notified and the lab rescheduled. The resident’s care plan was revised the same day to address noncompliance with treatment and care, with interventions such as leaving and returning later and providing education. However, the admission MDS, which included a BIMS score of 08 indicating moderate cognitive impairment, was coded to show that rejection of care behaviors were not exhibited, despite documentation of refusal of care during the 7‑day lookback period. The MDS Coordinator later acknowledged that rejection of care should have been coded based on the available documentation. Another resident with anemia, CKD stage 3, Alzheimer’s disease, and BPH experienced an episode of altered mental status and seizure activity, was found nonresponsive, and was transported to the hospital by EMS. Upon readmission, the resident was assessed as alert, verbally responsive, and oriented to person. A subsequent Significant Change MDS showed a BIMS score of 03, indicating severely impaired cognition, and was coded in Section E to reflect wandering behaviors occurring 4–6 days in the lookback period and placing the resident at significant risk of reaching a potentially dangerous place. Observations showed the resident seated in a Geri chair in the day room, alert to self only, with staff sitting next to him and reporting that he was not ambulatory and required supervision to prevent falls. Review of progress notes and the TAR for the month showed no documentation of wandering behaviors, and the unit manager stated the resident had not wandered for at least a couple of months. The MDS Coordinator reported that Section E was completed by the social worker, who later confirmed that the wandering behaviors were coded based on a past history rather than current behavior and acknowledged this was a mistake.
Failure to Implement Care-Planned Stairwell Escort for Oxygen-Dependent Resident
Penalty
Summary
Facility staff failed to implement a care plan intervention requiring an escort when a resident used the stairwell. The resident had been admitted with multiple diagnoses including COPD, chronic respiratory failure with hypoxia, and hypertension. The resident’s care plan, revised on 10/29/25, specified that the resident was to use the stairs when going down and coming back in, with an escort. A physician’s order dated 12/11/25 directed oxygen supplementation of 2–3 L/min via nasal cannula every shift for COPD. A quarterly MDS assessment documented that the resident had an intact BIMS score of 15, experienced shortness of breath with exertion, when sitting at rest, and when lying flat, and used oxygen therapy. On observation in the 2-north stairwell on 01/30/26 at 3:47 PM, the resident was seen alone, going down the stairwell, and was noticeably short of breath. The resident was on 3 L of oxygen via nasal cannula and was carrying a portable oxygen E-tank in a wheeled caddy. The resident stated that he did not like taking elevators and therefore used the stairs, and that a staff member had let him down to the stairwell, which required manual entry of a 4-digit code from the units. In a face-to-face interview shortly afterward, the Administrator acknowledged that the resident used the stairwell due to claustrophobia and stated that the resident should have someone with him when using the stairs, confirming that the care-planned escort intervention was not implemented.
Failure to Ensure Continuous Oxygen Supply for Resident on Oxygen Therapy
Penalty
Summary
Facility staff failed to ensure continuous oxygen therapy for a resident with COPD and chronic respiratory failure with hypoxia who had physician orders and care plan directives for continuous oxygen at 2–3 L/min via nasal cannula. The resident’s care plan, last revised on 10/29/25, specified that the resident was on oxygen therapy related to COPD, required continuous oxygen at 2–3 L/min, and for ambulatory residents, staff were to provide extension tubing or a portable oxygen apparatus. A physician’s order dated 12/11/25 directed oxygen supplementation at 2–3 L/min via nasal cannula every shift for COPD. A quarterly MDS assessment documented that the resident was cognitively intact with a BIMS score of 15, experienced shortness of breath with exertion, at rest, and when lying flat, and used oxygen therapy while in the facility. On 01/30/26 at 3:47 PM, the resident was observed alone in the 2-north stairwell, going down the stairs and noticeably short of breath, with oxygen via nasal cannula at 3 L/min and carrying a portable E-tank in a wheeled caddy. Upon inspection, the oxygen tank’s indicator was in the red area marked “0 refill,” indicating the tank was empty, meaning the resident was not receiving the ordered continuous oxygen. During a face-to-face interview shortly thereafter, the 2-south Unit Manager acknowledged that the resident’s oxygen tank was empty when the resident was observed short of breath and alone in the stairwell and stated that the assigned nurse was supposed to check and ensure that residents’ oxygen tanks were not empty when they left the unit. These observations and statements showed that staff did not ensure the resident’s continuous oxygen needs were met.
Failure to Perform Hand Hygiene During Meal Tray Distribution
Penalty
Summary
Facility staff failed to distribute and serve food in accordance with professional standards for food service safety during a dining observation on Unit 2 South. At approximately 12:30 PM, two staff members were observed in the hallway near the nurse's station delivering and distributing resident meal trays without performing required hand hygiene. This failure occurred despite regulatory requirements under 42 CFR §483.60(i) that employees must avoid bare-hand contact with food and must decontaminate hands by proper handwashing or use of hand sanitizers prior to starting meal delivery and prior to entering or exiting resident rooms or common areas. During the same observation, it was noted that the alcohol-based hand rub station located outside a resident room was not functioning because the handle used to dispense the sanitizer was broken. This meant that staff did not have access to a working alcohol-based hand rub at that location while they were delivering meals. The deficiency was identified during a surveyor observation and confirmed in a face-to-face interview with the Unit Manager, who acknowledged that staff had not performed hand hygiene while distributing the meal trays.
Failure to Meet Required Minimum Direct Nursing Care Hours
Penalty
Summary
Facility staff failed to meet State requirements for minimum direct nursing care hours on 01/30/26, the same day an Immediate Jeopardy was identified. Record review showed that with a census of 273 residents, the facility provided a total of 3.9 direct nursing hours per resident per day, which was below the required minimum daily average of 4.1 hours of direct nursing care per resident per day. During a face-to-face interview on 02/04/26 at 2:53 PM, the staffing coordinator acknowledged awareness of the 4.1-hour requirement and stated that staff were working hard to meet that requirement. No additional resident-specific clinical details, medical histories, or conditions at the time of the deficiency were provided in the report.
Inaccurate Documentation of Showers and Oxygen Use for Multiple Residents
Penalty
Summary
Facility staff failed to maintain accurate clinical documentation for multiple residents, resulting in records that did not truthfully reflect the care provided or the residents’ clinical status. For one resident with cirrhosis of the liver, muscle weakness, sickle-cell disease, and heart failure, the physician’s order directed showers twice weekly on specific days and times. The Treatment Administration Record and CNA documentation for a specified date in January showed that a shower with skin check was completed and that refusals were documented. However, during an interview that same day, the resident stated they did not take a shower, did not want one, and had communicated this to staff. A second resident, with hemiplegia/hemiparesis, COPD, and muscle disease, also had a physician’s order for showers twice weekly on designated days and shifts. The TAR and CNA documentation for the same January date indicated that a shower with skin check was completed and refusals were documented. In contrast, during an interview, this resident stated they did not take a shower and expressed that they would not shower at the facility. The RN assigned to both residents confirmed in an interview that the residents did not receive showers and were instead washed in bed, and acknowledged that she had documented showers as completed rather than documenting refusals and bed baths. For a third resident with COPD, chronic respiratory failure with hypoxia, and hypertension, the medical record included a care plan and physician’s order for continuous oxygen via nasal cannula at 2–3 L/min. A quarterly MDS assessment documented that the resident used oxygen therapy while in the facility. However, the quarterly Safe Smoker Assessment completed in January recorded that the resident did not have an order for continuous or PRN oxygen and identified the resident as a safe smoker who preferred cigarettes, with supervision recommended as protective equipment. In a subsequent interview, the resident stated they did not smoke and had not smoked in almost ten years. The unit manager later reviewed the Safe Smoker Assessment and physician’s orders and characterized the inaccurate documentation as an oversight.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Facility staff failed to provide adequate housekeeping services necessary to maintain a safe, clean, and comfortable environment for residents. During an environmental walkthrough, surveyors observed dust buildup under handwashing sinks, under beds, in wall corners, and around furniture in all resident rooms on two floors. Additional findings included soiled window tracks and frames with cobwebs in a dayroom, dirty and sticky floors in multiple resident rooms and common areas, and a strong urine odor in one resident care unit and a resident room. Toilets in two resident rooms were found soiled with dark stains, and trash cans in three rooms were dirty, with one having a broken step pedal. Further observations revealed stained privacy curtains in three resident rooms and dusty window blinds in five rooms. These environmental deficiencies were acknowledged by a facility employee during a face-to-face interview. The report does not mention any specific medical history or conditions of the residents affected, nor does it detail any immediate harm, but it documents the failure to maintain a clean and homelike environment as required.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Facility staff failed to maintain an effective pest control program, as evidenced by the presence of flies in three out of thirteen resident rooms on the third floor. In one room, numerous flies were observed, and further investigation revealed a trash can with a dark substance at the bottom that appeared to attract the flies. In another room, flies were found, and a dark, lumpy substance identified as human waste was discovered on the floor under a portable toilet near the foot of a bed. In a third room, flies were seen on the privacy curtain and on a pillow on one of the beds. These findings were confirmed through direct observation and staff interviews.
Failure to Ensure Correct Dose of Antidepressant Administered
Penalty
Summary
Facility staff failed to ensure that a resident received the correct dose of Trazodone, an antidepressant medication, as ordered by the physician. The resident, who had multiple diagnoses including Major Depressive Disorder, Dementia, and Metabolic Encephalopathy, had a physician's order for Trazodone 50 mg at bedtime, which was later changed to 0.5 tablet (25 mg) and then back to 50 mg. During a medication cart observation, it was found that only 25 mg tablets (half-tablets) were available, and there was no clear documentation or assurance that the correct 50 mg dose was being administered as ordered for five consecutive days. Review of the Medication Administration Record (MAR) indicated that staff documented administration of the 50 mg dose, but the Assistant Director of Nursing could not confirm whether two 25 mg tablets were given to make up the correct dose. The resident experienced an episode of lethargy and was sent to the emergency room for altered mental status, though no new findings were reported and the resident returned to the facility. The facility's policy required medications to be administered according to prescriber's orders and for staff to verify the right dose, but this was not ensured in this case.
Nurse Altered Medication Order Without Physician Notification
Penalty
Summary
Facility nursing staff failed to ensure that a resident received care and services according to accepted standards of clinical nursing practice. Specifically, a licensed registered nurse altered a medication order label for a resident's Trazodone prescription without documented evidence that the physician was notified or made aware of the change. The original physician's order directed a specific dosage, which was later discontinued and replaced with a new order. However, the medication blister packet on the medication cart was found to have been manually altered by facility staff to reflect a different dosage, with the label changed from 0.5 tablet to 2 tablets at bedtime. There was no documentation in the resident's progress notes indicating that the physician was consulted regarding the available tablet strength or the alteration of the medication order label. The resident involved had multiple diagnoses, including Major Depressive Disorder, Adjustment Disorder, Unspecified Dementia, and Metabolic Encephalopathy, and was assessed as having severely impaired cognitive function and moderate depression. Interviews with facility staff revealed a lack of clarity regarding who was responsible for altering the medication label, and the Assistant Director of Nursing indicated that nurses were allowed to use their own judgment to adjust medication orders for non-narcotic medications. This action was not supported by facility policy or standards of nursing practice, which require that medication orders be administered only as prescribed and that any concerns or discrepancies be communicated to the prescribing physician.
Inaccurate Medication Administration Documentation for Antidepressant
Penalty
Summary
Facility staff inaccurately documented the administration of Trazodone 50 mg to a resident with multiple diagnoses, including major depressive disorder, dementia, and metabolic encephalopathy. The resident's physician order specified Trazodone HCl 50 mg, one tablet by mouth at bedtime for depression. The Medication Administration Record (MAR) indicated that staff documented the administration of the full 50 mg dose on several consecutive days. However, observation of the medication cart revealed that only 25 mg half-tablets of Trazodone were available for the resident, with the blister pack labeled for administration of 0.5 tablet (25 mg) at bedtime. There was no evidence that the resident received the full 50 mg dose as ordered, and staff could not confirm whether two half-tablets were given to equal the prescribed dose. The Assistant Director of Nursing acknowledged the discrepancy and was unable to verify the actual administration of the correct dosage.
Failure to Respect Resident's Dignity During Communication About Personal Possessions
Penalty
Summary
Facility staff failed to honor a resident's right to be treated with respect and dignity when a resident expressed concern about her television not working. During an observation, the resident, who had a history of hemiplegia, cervical disk disorder, morbid obesity, and moderate cognitive impairment, stated that her television had not worked for about a week. As she was speaking, the assigned RN interrupted her, disputing the resident's statement by saying the television had been working earlier in the week. The resident later reported feeling disrespected by the interruption, stating that the staff member made her feel as though she was unaware of her own situation. The RN explained that she interrupted because the resident sometimes experienced confusion and she wanted to clarify the situation. The administrator confirmed there had been disruptions in cable service due to a provider change, which may have affected the television's functionality.
Failure to Maintain Required Room Temperature for Resident
Penalty
Summary
The facility failed to maintain the required comfortable air temperature range of 71°F to 81°F for a resident with multiple diagnoses, including hemiplegia, cervical disk disorder, and morbid obesity. The resident, who had a moderately impaired cognitive status, reported that her room had been cold for the past week and that it was colder at night. During two separate observations, the room temperature was measured at 66°F and 68°F, both below the required range. The resident was observed lying in bed with a heavy blanket and stated she had informed nursing staff about the cold temperature, though she could not recall the nurse's name. Interviews with the Maintenance Director and Administrator revealed that they were unaware of the temperature issue in the resident's room. They stated that room temperatures are monitored daily but not recorded, and that the electronic system for logging maintenance requests is rarely used, with most issues reported in person. A subsequent temperature check in the resident's room showed a temperature of 73°F, but the resident continued to report feeling cold, especially at night.
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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