Harborside Health & Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 4601 Martin Luther King Jr Avenue Sw, Washington, District Of Columbia 20032
- CMS Provider Number
- 095024
- Inspections on file
- 23
- Latest survey
- March 3, 2026
- Citations (last 12 mo.)
- 10 (1 serious)
Citation history
Health deficiencies cited at Harborside Health & Rehabilitation during CMS and state inspections, most recent first.
Staff failed to provide AHA-compliant CPR to a full-code resident with a tracheostomy who was found unresponsive, pulseless, and not breathing on the floor with a dislodged trach. The supervising nurse initiated chest compressions but did not provide rescue breaths via the trach and left the resident alone to seek help at the nurses’ station instead of using the call light or shouting for assistance. A Rapid Response was called instead of a Code Blue despite the resident being pulseless and apneic. When an RT arrived, several staff were present but not performing CPR; the RT then began compressions and rescue breathing with an Ambu bag, reinserted the dislodged trach, and continued CPR with another RT until EMS took over. These actions and inactions, which did not follow facility policy based on AHA guidelines, led to a cited deficiency under F678 for failure to accurately provide CPR.
A resident with a history of epilepsy and a physician order for Lacosamide 200 mg BID did not receive 10 scheduled doses of this anticonvulsant over several days. The controlled drug record showed the last available dose was given, but no timely refill was obtained, and a prescription was not faxed to the pharmacy until days later. During this period, MAR entries reflected held or other non-administered doses, while an LPN falsely documented that some doses were given despite no evidence of medication removal from Omnicell or delivery from the pharmacy. The resident experienced multiple seizures, changes in mental status, and episodes of emesis, resulting in emergency transfers and hospital treatment for seizures and bacteremia. The physician was not notified that multiple doses had been missed.
Facility staff did not meet the State-required minimum average of 4.1 hours of direct nursing care per resident per day, providing only 4.0 hours on a day when the census was 117. On that same day, a resident with a tracheostomy was found in the doorway of their room with the trach dislodged during the early morning hours, and an IJ related to CPR requirements was later identified. The staffing coordinator confirmed that the required staffing level was not achieved and attributed this, in part, to an inability to obtain replacements for staff who called out.
Facility staff failed to comply with their abuse and incident reporting policy by not reporting, within the required 2-hour timeframe, a serious incident in which a resident with multiple complex conditions (including acute respiratory failure with hypoxia, epilepsy, dysphagia post-CVA, DM, and schizophrenia) was found unresponsive on the floor in the doorway of the room with a dislodged trach, and was later pronounced deceased after CPR and ACLS by EMS. The incident was reported to the State Agency approximately 16.5 hours later, and when it was reported, staff did not disclose that the event had resulted in serious injury, harm, or death, despite having knowledge of the resident’s death.
Facility staff failed to follow policy requiring a spare tracheostomy tube at the bedside for a resident with acute and chronic respiratory failure, COPD, and other comorbidities who received oxygen therapy, suctioning, and trach care. During observation, the resident was noted sitting in a wheelchair with a trach and speaking valve, but no spare trach tube was found in the room despite searches by an LPN and an RT. The Director of Respiratory Therapy stated that respiratory therapy is responsible for placing spare trachs and emergency equipment at the bedside for all airway patients, yet the assigned RT confirmed there was no spare trach available for this resident and could not explain the omission.
Staff failed to demonstrate required competencies in two separate situations involving two residents. In one case, a full-code resident with a tracheostomy and multiple comorbidities was found unresponsive, pulseless, and not breathing on the floor; the supervising nurse left the resident to run for help instead of calling out or using the call system, did not immediately activate a Code Blue, and provided only chest compressions without rescue breaths via the trach, contrary to the facility’s AHA-based CPR policy. In the other case, a resident with epilepsy and a seizure disorder did not receive ordered Lacosamide 200 mg BID for multiple doses: the refill prescription was not timely faxed, available doses in the Omnicell were not used, the MAR showed missed doses while an LPN charted some doses as given without supporting Omnicell or controlled-drug records, and the physician was not notified of the missed anticonvulsant doses despite documented seizure events.
Staff failed to consistently reconcile and document controlled medications when administered, as shown by three separate discrepancies between narcotic control sheets and blister pack counts for residents receiving Tramadol, Pregabalin, and Lacosamide. During controlled substance reconciliations on two units, an LPN and an RN each had instances where the recorded remaining doses on the controlled medication forms exceeded the actual pills in the blister packs, and both nurses acknowledged they had given the medications but forgot to sign the narcotic sheets at the time of administration.
A resident with epilepsy, acute respiratory failure, and dysphagia had an order for Lacosamide 100 mg tablets via PEG tube that ended after a defined 30-day period, but 23 tablets remained stored in the narcotic box well beyond the discontinuation date. During a medication cart audit, an LPN confirmed the resident was no longer receiving the drug and could not explain why it was still present, and the DON later acknowledged that required monthly cart audits may not have been completed and was unaware the medication remained on hand. This resulted in a controlled substance not being disposed of according to the facility’s policy and accepted standards for controlled drug handling.
A resident with epilepsy and intact cognition had a physician order for Lacosamide 200 mg BID for seizure precaution. The controlled drug record showed the last available dose was given on one evening, with zero tablets remaining thereafter, while the MAR reflected that an LPN documented additional nighttime doses on three later dates. Review of Omnicell inventory showed Lacosamide tablets in stock but no documentation that any were removed or delivered to match the charted administrations. A facility-reported incident confirmed that the resident did not receive the doses that had been signed out by the LPN, indicating false documentation of medication administration.
Staff failed to follow established protocols for respiratory care when a resident's tracheostomy tube became dislodged. Instead of calling a rapid response or respiratory therapist as required, nursing staff attempted to reinsert the tube themselves without checking vital signs or airway patency, and without proper hand hygiene. The nurse involved did not have documented competency for this procedure, and the facility's policy was not followed, though the resident did not suffer harm.
A resident with a tracheostomy, who was at high risk for self-decannulation, had their trach tube reinserted by a nurse who was not trained or qualified to perform the procedure. Facility policy required a rapid response and reinsertion only by a respiratory therapist or qualified practitioner, but these steps were not followed. The nurse did not assess airway patency or vital signs before reinsertion, and documentation showed no evidence of required training or competency for this task. The resident did not experience harm from the incident.
Failure to Provide AHA-Compliant CPR to Tracheostomy-Dependent Full-Code Resident
Penalty
Summary
Facility staff failed to accurately provide cardiopulmonary resuscitation (CPR) to a resident who was a full code and dependent on a tracheostomy, resulting in a deficiency cited under 42 CFR 483.24, F678, Cardiopulmonary Resuscitation. The facility’s CPR policy required adherence to American Heart Association (AHA) guidelines, including immediate initiation of CPR when an individual is found unresponsive with absent or abnormal breathing, continuous chest compressions at a rate of 100–120 per minute, provision of rescue breaths, and not leaving the person alone except when absolutely necessary to call for help. The AHA guidance referenced in the report also specified that CPR for a person with a tracheostomy involves 30 chest compressions followed by 2 breaths delivered via the tracheostomy tube using an Ambu bag or mouth-to-trach, and that if the tracheostomy tube is dislodged or blocked, it should be replaced or the stoma covered to provide rescue breathing. The resident involved had multiple significant medical diagnoses, including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia. The resident had a physician’s order for full code status and care plans identifying risks for respiratory and cardiac complications, with interventions such as administering medications and treatments as ordered, monitoring for signs and symptoms of respiratory and cardiac complications, and providing tracheostomy care and respiratory therapy services. An admission MDS indicated the resident was cognitively intact with a BIMS score of 13, had functional limitations in upper extremities but no lower extremity impairment, used a walker, required partial/moderate assistance for some transfers, and received oxygen, tracheostomy care, and respiratory therapy. During night shift rounds at approximately 3:00 AM, the nurse supervisor (Employee #6) found the resident lying supine on the floor near the doorway, unresponsive, without a pulse or respirations, with the inner cannula of the tracheostomy tube dislodged. The nurse supervisor reported performing a brief assessment, confirming the absence of pulse and respirations, and initiating chest compressions for about three minutes but did not provide any rescue ventilation via the tracheostomy site using an Ambu bag or other method. Contrary to AHA guidance and facility policy that require not leaving a collapsed person who needs CPR, the nurse supervisor stopped CPR and left the resident alone to go to the nurses’ station to get help, stating she did not use the call light or shout for help because it was 3:00 AM and she did not want to wake other residents. She also initially called a “Rapid Response” rather than a “Code Blue,” despite the resident being pulseless and not breathing. When the respiratory therapist (Employee #9) arrived in response to the calls, the resident was on the floor on his back with several people present who were not administering CPR. The respiratory therapist assessed that the resident was not breathing, retrieved the Ambu bag from the bedside, connected it to oxygen, and began chest compressions with one hand while providing rescue breaths with the other. The therapist observed that the tracheostomy tube was dislodged and on the floor and was able to reinsert it without incident before continuing CPR with assistance from another respiratory therapist. The DON later confirmed that staff are trained that a Code Blue is automatic when someone collapses and has no pulse or is not breathing. The evidence showed that staff actions deviated from AHA-based facility policy by leaving the resident during CPR, failing to provide appropriate rescue breathing via the tracheostomy, and initially calling a Rapid Response instead of a Code Blue for a pulseless, non-breathing resident, leading to the cited deficiency. The resident was subsequently pronounced deceased at 3:51 AM after EMS arrived and continued advanced cardiovascular life support. The surveyors determined that these failures constituted an Immediate Jeopardy situation related to the provision of CPR under F678.
Removal Plan
- Remove Employee #6 from resident care pending investigation and re-education.
- Re-educate all licensed nurses on AHA CPR/BLS requirements.
- Re-educate all licensed nurses on performing continuous chest compressions without leaving the resident.
- Re-educate all licensed nurses on proper ventilation for residents with tracheostomies (use of Ambu bag via trach; management of dislodged trach).
- Re-educate all licensed nurses on clear differentiation between Code Blue and Rapid Response.
- Include in education: 30 compressions at 100-120/minute.
- Include in education: rescue breathing via tracheostomy.
- Include in education: procedure if tracheostomy becomes dislodged.
- Require all licensed staff to maintain current AHA BLS certification.
- Implement mock Code Blue drills.
- Post Code Blue vs Rapid Response criteria at nurses' stations.
- Conduct an immediate 100% chart audit of all residents with physician orders for fall/safety assessments to verify appropriateness and implementation.
- Verify all physician orders for fall/safety assessments on MAR/TAR are being implemented.
- Address any missing documentation for ordered assessments.
- Re-educate nurses on required documentation of ordered assessments.
- Conduct a 100% audit of care plans for residents at risk for falls and update them to include more than one individualized, multi-factor fall prevention intervention.
- Provide education on care plans, Code Blue vs Rapid Response, CPR response and compliance, and physician orders/implementation of fall/safety assessments.
- Provide education by the educator/designee for all licensed staff starting night shift.
- Provide education for all other licensed staff prior to or at the start of their shift.
- Continue training until all licensed staff have been educated.
Failure to Administer Ordered Anticonvulsant Leading to Multiple Seizures and Hospitalization
Penalty
Summary
Facility staff failed to provide ordered anticonvulsant medication to a resident with a convulsion disorder, resulting in missed doses over several days. The resident had a history of convulsions related to head injury, hypertension, and spastic hemiplegia, with an active diagnosis of epilepsy and an order for Lacosamide 200 mg orally twice daily for seizure precautions. The resident’s care plan required seizure medication to be given as ordered and monitored for effectiveness and side effects. The controlled drug record showed the last available dose of Lacosamide was administered on 06/06/25 at 10 PM, with a count of zero tablets remaining, and the facility’s policy required refills to be ordered at least three days before the last dose. From 06/07/25 through 06/12/25, the Medication Administration Record (MAR) documented that multiple scheduled doses of Lacosamide were not administered, with entries of “5=Hold/See Progress Notes” and “9=Other/See Progress Notes” at several administration times. Despite this, an LPN documented check marks and initials on the MAR indicating that Lacosamide was administered on three evenings, even though there was no evidence that the medication had been removed from the Omnicell or delivered from the pharmacy, and the controlled drug disposition form showed no doses available after 06/06/25. Pharmacy records confirmed that no additional doses had been ordered or delivered after that date, and a prescription written on 06/06/25 was not faxed to the pharmacy until 06/12/25. During the period when doses were missed, the resident experienced changes in condition and seizure activity. On 06/09/25, security staff reported that the resident was not responding as usual, and the resident was assessed with the MD made aware but no new orders given. On 06/11/25, the resident had a seizure after smoking, with tongue biting and bleeding, and was transported to the hospital. The resident returned later that day, and on 06/12/25, nursing documentation noted that the resident did not have Lacosamide 200 mg available. That same morning, the resident had another tonic-clonic seizure, followed by another seizure and an episode of coffee-brown emesis, leading to a rapid response and transfer to the hospital. The resident was later discharged from the hospital after treatment for seizures and bacteremia. The facility’s review concluded that the resident missed a total of 10 doses of Lacosamide, that staff did not timely fax the prescription, did not administer available doses from the Omnicell, and did not notify the physician that multiple doses had been missed.
Failure to Meet State Minimum Direct Care Staffing Requirement
Penalty
Summary
Facility staff failed to meet the State requirement of providing a minimum daily average of 4.1 hours of direct nursing care per resident per day on 02/22/26, when the census was 117 residents and the facility’s total direct care staffing level was 4.0 hours. On that same date, a facility reported incident documented that at approximately 3:00 AM, Resident #5 was found in the doorway of his room with his tracheostomy dislodged. An Immediate Jeopardy was identified at 42 CFR 483.24, F678, related to cardiopulmonary resuscitation on 02/25/26 at 3:40 PM. During a face-to-face interview on 03/03/26, the staffing coordinator calculated the total direct care staff, acknowledged that the 4.1-hour requirement was not met on 02/22/26, and stated that staffing had generally been good but that on some days replacements could not be obtained for staff who called out. The deficiency centers on the facility’s failure to comply with State minimum direct care staffing requirements on 02/22/26, in the context of an incident where a resident with a tracheostomy was found with the trach dislodged during the early morning hours, and the subsequent identification of Immediate Jeopardy related to cardiopulmonary resuscitation requirements.
Failure to Timely Report Resident Death and Serious Incident to State Agency
Penalty
Summary
Facility staff failed to timely report an incident of suspected abuse, neglect, or mistreatment, as required by the facility’s Abuse Investigation and Reporting policy, which mandates that alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but not later than two hours. The incident involved a resident with multiple diagnoses, including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia, who was admitted on a prior date. At approximately 3:00 AM, during a supervisor’s round, the resident was found on the floor in the doorway of the room, lying in a supine position, unresponsive, with the tracheostomy dislodged. A rapid response was called, CPR was initiated by the code team, and EMS (911) arrived and continued ACLS protocols. Despite the seriousness of the event and the resident being pronounced deceased at 3:51 AM after several rounds of CPR, the facility did not report the incident to the State Agency until approximately 7:26 PM the same day, about 16.5 hours after the incident occurred. The Facility Reported Incident documented that the resident was found in the doorway with the trach dislodged and that an investigation was underway, but at the time of the report, facility staff did not disclose that the incident had resulted in serious injury, harm, or death, even though they had knowledge of the resident’s death. During a face-to-face interview, the DON acknowledged the findings and made no comment.
Failure to Maintain Required Spare Tracheostomy Tube at Bedside
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care by not maintaining a required spare tracheostomy tube at the bedside for one resident with a tracheostomy. The facility’s policy titled “Unplanned Decannulation: Risk Assessment, Precautions and Interventions” dated 12/09/25 stated that a replacement airway must be kept at the bedside for all airway patients. The resident was admitted with multiple diagnoses including acute and chronic respiratory failure with hypoxia, chronic kidney disease, and hyperkalemia, and had a care plan for risk of respiratory complications related to COPD and respiratory failure. The resident’s MDS showed intact cognition (BIMS score 14) and documented that the resident received oxygen therapy, suctioning, and trach care. A physician’s order directed use of a Shiley trach, size 6.5 cuffless, with specified FiO2 and oxygen saturation parameters. During an observation, the resident was seen in her room in a wheelchair with a tracheostomy and speaking valve in place, and no spare trach tube was found anywhere in the room. The assigned LPN searched behind the bed, on the bed, and in the bedside drawers and confirmed there was no spare trach, stating she did not know the resident did not have one and suggesting it might be on the respiratory cart. In a subsequent interview, the Director of Respiratory Therapy stated that respiratory therapy is responsible for setting up and placing spare trachs and other emergency equipment, such as an Ambu bag, at the bedside for all airway patients except laryngectomy patients, and confirmed that all airway patients must have a spare trach at the bedside in case of accidental dislodgement. When instructed to verify the presence of a spare trach, the assigned respiratory therapist went to the resident’s room, searched, and reported there was no spare trach for the resident, stating he did not know why and that he had just arrived.
Failure to Provide Competent CPR and Ensure Continuous Anticonvulsant Therapy
Penalty
Summary
Facility staff failed to demonstrate appropriate competencies and skill sets in providing safe emergency care to a resident who was a full code with a tracheostomy. The resident had multiple diagnoses including acute respiratory failure with hypoxia, epilepsy, dysphagia following cerebral infarction, diabetes mellitus, and schizophrenia, and received oxygen, tracheostomy care, and respiratory therapy services. During a night shift supervisor round at approximately 3:00 AM, the nurse supervisor found the resident on the floor near the doorway, lying supine, unresponsive, without a pulse or respirations, and with the inner cannula of the tracheostomy tube dislodged while the oxygen tubing remained connected. The nurse supervisor reported that she performed a brief assessment, checked for pulse and respirations, and initiated CPR. She stated she provided chest compressions for about three minutes but did not provide ventilations via the tracheostomy site using an Ambu bag or any other form of rescue breathing, despite the facility’s CPR policy referencing American Heart Association (AHA) guidelines that include providing breaths after chest compressions. Instead of immediately calling for help from the resident’s room, she left the unresponsive resident alone to run to the nurse’s station to get assistance, explaining that she did not use the call light or shout for help because it was 3:00 AM and she did not want to wake other residents. She further stated that she initially called a “Rapid Response” rather than a “Code Blue,” even though the resident was unresponsive, pulseless, and not breathing, and she had already been performing CPR without response. These actions were inconsistent with the facility’s Emergency Procedure – Cardiopulmonary Resuscitation policy, which directed staff to immediately activate the emergency response system (Code Blue), call 911, and provide CPR in accordance with AHA guidelines, including chest compressions and rescue breaths. The evidence showed that staff did not immediately activate a Code Blue, did not promptly call for help from the scene, and did not accurately provide CPR, specifically failing to provide ventilations via the tracheostomy site. The resident was later pronounced deceased at the hospital. Review of the nurse supervisor’s file showed she had been certified/trained in CPR/Basic Life Support using AHA guidelines, yet the care provided did not follow those guidelines. Facility staff also failed to ensure that another resident consistently received an ordered anticonvulsant medication, Lacosamide 200 mg, prescribed twice daily for seizure precaution. This resident had diagnoses including convulsions, hypertension, spastic hemiplegia affecting the left dominant side, and an active diagnosis of epilepsy with status epilepticus, and the care plan directed staff to give seizure medication as ordered and monitor effectiveness. A controlled substance record showed that the last available dose from one supply was administered on a specific date at 10:00 PM, with the count then at zero. The prescription for Lacosamide was written on a later date but was not faxed to the pharmacy until several days afterward, contrary to facility policy requiring refills to be reordered at least three days before the last dose. During the period when the resident should have been receiving Lacosamide, the Medication Administration Record (MAR) showed multiple entries where the medication was not administered, documented with codes indicating “hold/see progress notes” or “other/see progress notes.” On several later dates, an LPN documented on the MAR that Lacosamide 200 mg was administered at 10:00 PM, but there was no corresponding documentation that the medication had been removed from the Omnicell or delivered from the pharmacy, and the controlled drug disposition form showed no doses available after the earlier date. At the same time, Omnicell inventory records showed that six Lacosamide 200 mg tablets were in stock and available in the facility, yet they were not used for the resident. The resident experienced seizures, including one episode after smoking and another associated with a change in mental status, leading to rapid responses and transfers to the hospital. The physician was not made aware that the resident had missed multiple doses of Lacosamide, despite the missed administrations documented on the MAR.
Failure to Properly Reconcile and Document Controlled Medications
Penalty
Summary
Facility staff failed to ensure controlled substances were properly reconciled by not signing controlled medication forms at the time medications were administered for three residents. For one resident with neuralgia, neuritis, hypertension, encephalopathy, severe cognitive impairment, and an order for PRN Tramadol 50 mg every six hours for right arm pain, a controlled substances reconciliation on Unit 2 East showed a discrepancy: the narcotic control sheet documented 2 tablets remaining, while the blister pack contained only 1 tablet. The LPN conducting the reconciliation stated that the medication had just been given and acknowledged forgetting to sign the controlled substance form when the dose was removed and administered. A second resident with pain, neuralgia, neuritis, muscle spasms, intact cognition, and an order for Pregabalin 150 mg twice daily for neuropathy pain also had a discrepancy during the same reconciliation on Unit 2 East. The controlled substance form showed 18 capsules remaining, but the blister pack contained 17, and the LPN reported forgetting to sign when the medication was given. A third resident with conversion disorder with seizures or convulsions, Crohn’s disease, dementia, severe cognitive impairment, and an order for Lacosamide 200 mg twice daily for seizures had a similar issue on Unit 3 West. During reconciliation, the controlled substance form indicated 18 tablets remaining, while the blister pack had 17 tablets; the RN stated that they were supposed to sign the narcotic sheet when pulling the medication to give to the resident, implying this had not been done. These findings showed that controlled substances were not consistently reconciled as required when administered.
Failure to Timely Dispose of Discontinued Controlled Substance
Penalty
Summary
Facility staff failed to follow their policy for timely disposal of a controlled substance for one resident. The facility’s policy on discarding and destroying medications, dated 12/09/25, required that disposal of controlled substances occur immediately and no longer than three days after discontinuation. Resident #8, admitted with diagnoses including epilepsy, acute respiratory failure, and dysphagia, had a physician’s order for Lacosamide 100 mg tablets via PEG tube twice daily from 11/28/25 through 12/28/25. The medication was therefore discontinued on 12/28/25. On 02/26/26, the Administrator provided a list of residents currently prescribed and taking Lacosamide, and Resident #8 was not on that list. During a medication cart audit on Unit 2 East the same day, an LPN and the surveyor found 23 Lacosamide 100 mg tablets for Resident #8 stored in the narcotic box, despite the medication having been discontinued for 59 days. The LPN stated they did not know why the resident still had the medication and confirmed the resident was not receiving it. In a subsequent interview, the DON acknowledged that monthly cart audits were supposed to be done at the beginning of each month, was unsure if one had been done for January, and was not aware that Resident #8’s Lacosamide tablets were still on hand. As a result, the controlled substance was not disposed of within the timeframe required by facility policy.
False Documentation of Anticonvulsant Administration
Penalty
Summary
Facility staff failed to maintain accurate, resident-specific medical records when an LPN falsely documented administration of an anticonvulsant medication. A resident with diagnoses including convulsions, hypertension, and spastic hemiplegia had a physician’s order for Lacosamide 200 mg by mouth twice daily for seizure precaution. A quarterly MDS showed the resident had intact cognition (BIMS score 15), no rejection of care behaviors, an active diagnosis of epilepsy with status epilepticus, and receipt of anticonvulsant medications. The controlled drug receipt/record/disposition form for Lacosamide indicated that the last available dose was administered on 06/06/25 at 10 PM by the LPN, with a documented count of zero tablets remaining. Despite the controlled drug record showing no remaining tablets after 06/06/25, the June 2025 MAR showed that the same LPN documented administration of Lacosamide 200 mg to the resident on 06/07/25, 06/09/25, and 06/11/25 at 10 PM. Review of the Omnicell inventory for June 2025 showed six Lacosamide 200 mg tablets in stock and available in the facility, but there was no documented evidence that any Lacosamide tablets were removed from the Omnicell or delivered from the pharmacy corresponding to the doses charted on those dates. A facility-reported incident stated that, upon review of the controlled drug disposition form, the resident had not received the medication on the dates for which the LPN had signed the MAR, demonstrating that the LPN falsely documented administration of the Lacosamide doses.
Failure to Follow Tracheostomy Decannulation Protocols
Penalty
Summary
Facility staff failed to provide necessary respiratory care to a resident following the decannulation of her tracheostomy tube, as required by the resident's comprehensive care plan and the facility's policy. The resident, who had a history of tracheostomy, acute and chronic respiratory failure, and was at high risk for self-decannulation, was found by staff with her trach tube either partially or completely out on multiple occasions. Despite clear physician orders and care plan interventions outlining the steps to take in the event of decannulation—including calling a rapid response team, assessing airway patency, and ensuring only qualified practitioners reinsert the trach tube—these protocols were not followed. On the day of the incident, staff observed the resident with her trach tube either halfway out or completely out, with no signs of respiratory distress. Instead of calling a rapid response or respiratory therapist as required, nursing staff attempted to reinsert or adjust the trach tube themselves. Interviews revealed that the nurses involved did not check the resident's vital signs or airway patency before reinserting the tube, and did not perform hand hygiene prior to the procedure. The facility's Director of Respiratory confirmed that nurses are not trained or authorized to reinsert trach tubes, and that the established protocol was not followed in this case. Documentation and staff interviews further indicated that the nurse who performed the reinsertion did not have documented competency or training to be considered a qualified practitioner for this procedure. The incident was reported by a speech therapist who witnessed the event and expressed concern about the lack of proper protocol adherence. Although the resident did not suffer harm as a result of this deficient practice, the failure to follow established respiratory care protocols and the resident's care plan constituted a deficiency.
Unqualified Nurse Reinserted Tracheostomy Tube After Decannulation
Penalty
Summary
Facility staff failed to demonstrate appropriate competencies and skills in providing safe nursing care for a resident with a tracheostomy. The resident, who had a history of self-decannulation and multiple respiratory diagnoses, was at high risk for airway complications. The care plan and facility policy required that, in the event of unplanned decannulation, a rapid response should be called and only a qualified practitioner, such as a respiratory therapist, should reinsert the tracheostomy tube. Despite these protocols, a registered nurse who was not trained or documented as a qualified practitioner reinserted the resident's tracheostomy tube after it was found dislodged. On the day of the incident, a speech therapist discovered the resident's tracheostomy tube had come out and notified nursing staff. Two nurses entered the room and one of them reinserted the tube without performing hand hygiene, checking vital signs, or assessing airway patency or oxygenation status. The resident showed signs of pain during the procedure. The nurse involved later confirmed that she did not follow the facility's protocol, did not call for a rapid response, and was not trained to reinsert a tracheostomy tube. Documentation and staff interviews confirmed that the nurse was not qualified to perform this procedure and that the required steps outlined in the resident's care plan and facility policy were not followed. The incident was reported by staff and confirmed through interviews and record review. The facility's Director of Respiratory and other leadership staff stated that only respiratory therapists or specifically trained staff are permitted to reinsert tracheostomy tubes, and that all nurses are instructed on the tube out procedure annually. However, there was no evidence that the nurse who performed the reinsertion had received the necessary training or competency validation. The resident did not suffer harm as a result of this incident.
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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