Ingleside At Rock Creek
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 3050 Military Road Nw, Washington, District Of Columbia 20015
- CMS Provider Number
- 095028
- Inspections on file
- 16
- Latest survey
- March 26, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ingleside At Rock Creek during CMS and state inspections, most recent first.
A resident with dementia and a history of exit-seeking behaviors eloped from a secured unit after following a dining services employee through a locked door and accessing an unprotected service elevator. The resident was found outside near a busy intersection after being unsupervised for about 20 minutes. Staff were aware of the resident's frequent wandering and exit attempts but did not provide adequate supervision or timely reporting, resulting in a deficiency related to accident prevention and resident safety.
Facility staff did not develop or implement person-centered care plans for two residents, including one with dysphagia and another requiring discharge planning for ongoing cancer treatment. Despite documented clinical needs and therapy recommendations, care plans addressing these needs were missing from the medical records, and staff interviews confirmed the omissions.
Facility staff did not consistently document that the IDT reviewed or revised care plans or held care plan conferences after required MDS assessments for multiple residents with complex medical needs. This included residents with cognitive impairment, chronic illnesses, and recent falls, with missing documentation noted after both quarterly and comprehensive assessments. Staff interviews confirmed the absence of required documentation for these care planning activities.
Surveyors found that for several residents, the attending physician did not document responses to pharmacist-identified medication regimen irregularities as required. Pharmacist recommendations and physician responses were often missing from the medical record or stored separately, and in some cases, could not be located at all. This deficiency was confirmed through record review and staff interviews, affecting residents with complex medication needs and multiple diagnoses.
A resident with cognitive impairment and physical limitations spilled hot coffee on her chest, resulting in a blister. The assigned RN did not immediately notify the physician or administrative staff about the incident, only reporting it several hours later after the injury became apparent, despite having received prior training on timely incident reporting.
A resident with dementia and a history of wandering eloped from the facility and was found outside near a busy intersection. Although the resident was identified as an elopement risk and interventions were in place, the facility did not submit the results of its investigation into the incident to the State Survey Agency within the required timeframe.
The facility did not submit the results of investigations to the State Survey Agency within the required timeframe for three incidents involving residents with significant injuries or elopement. In each case, while incidents were documented and some investigations were conducted, there was no evidence that the results were reported as required, and in one case, the investigation was delayed and incomplete.
Facility staff did not complete a required Level I PASARR screening for a resident with multiple mental health diagnoses who remained in the facility for more than 30 days. The initial screening was incomplete, and no updated assessment was performed despite the resident's continued stay and severe cognitive impairment.
A physician did not consistently review or reconcile a resident's medication orders, specifically for Metoprolol, during multiple required visits. Despite several changes to the medication regimen and repeated pharmacy requests for clarification, discrepancies persisted between the active orders and the documented medication lists. The physician's delayed response to pharmacy recommendations and lack of documentation regarding medication changes led to ongoing inconsistencies in the resident's care.
A resident with multiple chronic conditions received Metoprolol in a manner inconsistent with current physician orders due to a nurse's repeated transcription errors. The nurse used an electronic health record function that carried over outdated special instructions, resulting in the continued administration of both 50 mg and 25 mg doses after the 25 mg order was discontinued. Staff followed these erroneous instructions as documented in the MAR, and the error persisted for several months.
A resident with severe cognitive impairment and multiple diagnoses was found to have an opened bottle of ProSource liquid supplement in their medication drawer that lacked a date opened sticker, contrary to facility policy requiring such labeling for opened medications. The deficiency was confirmed during a medication storage observation and staff interview.
Surveyors identified multiple sanitation and food storage deficiencies, including expired eyewash solutions, leaking dishwashing equipment, lack of handwashing supplies, dust and foreign substances in food storage areas, and spoiled ready-to-eat foods leaking in the walk-in refrigerator. These issues were confirmed by staff during interviews.
The facility did not meet the required minimum daily average of RN care hours per resident on several days, as staffing records showed RN coverage below the mandated 0.6 hours per resident. The DON acknowledged these staffing shortfalls during an interview.
Staff did not maintain the kitchen's only dishwashing machine in proper working order, as it was observed to spurt water solution from both sides during operation. This issue was confirmed by an employee.
Staff failed to maintain an effective pest control program, as flying insects were observed around a handwashing sink in the east-wing kitchen. A staff member confirmed the facility receives regular pest extermination services and acknowledged the presence of the insects.
The facility staff failed to ensure that residents had collaborative hospice care plans between the hospice agency and the facility. Five residents did not have person-centered hospice care plans that included a description of the care, services, and frequency of visits to be provided by the contracted hospice provider. The medical records lacked the most recent hospice plans of care, and there was no documented evidence of collaboration between the facility staff and the hospice staff.
Facility staff failed to notify two Medicaid residents when their account balances reached within $200 of the SSI resource limit, potentially affecting their Medicaid eligibility. The Director of Nursing could not provide evidence of notification letters being sent or received.
The facility staff failed to provide adequate surety bond coverage for residents' personal funds. The bond amount was $100,000.00, but the Resident Funds Trust Account statements for August to October 2023 showed balances exceeding this amount. An employee confirmed the findings during an interview.
The facility failed to notify a resident's responsible party of significant changes in the resident's medical status and an unwitnessed fall, despite policy requirements. Interviews confirmed the lack of communication, and the Director of Nursing acknowledged the oversight.
The facility failed to implement its policies and procedures for investigating a resident's unwitnessed fall. Despite the resident being assessed and transferred to the hospital, the investigation was incomplete, lacking thorough documentation and evidence.
The facility staff failed to conduct a thorough investigation into an unwitnessed fall involving a resident with multiple diagnoses, including an unspecified fracture and repeated falls. The incident was reported, and the resident was transferred to the hospital, but the investigation lacked comprehensive details. Interviews with staff confirmed the investigation was incomplete.
The facility staff failed to provide written notice of the bed hold policy to a resident or their responsible party upon transfer to the emergency room. The medical record review revealed no documented evidence of the required written notice specifying the proposed action, reason for transfer, date of transfer, resident's destination, and the bed hold policy.
Facility staff failed to accurately code a resident for hospice on a quarterly MDS assessment. The resident, admitted with multiple diagnoses and an informed consent for hospice services, was incorrectly marked as not receiving hospice. A review showed no evidence that hospice services had stopped, and an employee confirmed the error.
Facility staff failed to update the care plan for a resident with severely impaired cognition and bilateral hand contractures to include the use of palm protectors, despite physician's orders and documented use. The Assistant Director of Nursing acknowledged the oversight during an interview.
Facility staff failed to provide adequate supervision for two residents identified as high fall risks, resulting in an unwitnessed fall and an injury of unknown origin. Additionally, three oxygen tanks were unsafely stored, presenting an accident hazard.
The facility staff failed to reconcile a resident's controlled substance medication with the pharmacy delivery staff and did not record the receipt of Fentanyl patches on the narcotic medication reconciliation log. Additionally, the same nurse signed the shift narcotic count sheet as both the nurse coming on duty and the nurse going off duty on multiple occasions, contrary to the facility's policy.
Facility staff failed to acknowledge and/or respond to the pharmacist's medication regimen review recommendations for two residents. Despite attempts by the DON to locate these recommendations, they were not found in the residents' medical records, and there was no documented evidence that the physician responded to or reviewed the pharmacist's recommendations.
A resident with severe dementia and a femur fracture was found unrousable with three Fentanyl patches on her body, contrary to the physician's order of one patch every 72 hours. The error was confirmed by a registered nurse and the Director of Nursing, who noted that the patches were not removed as scheduled.
Facility staff failed to store and distribute food under sanitary conditions, as evidenced by expired V8 vegetable drinks found in the kitchen on both the East and [NAME] sides of the facility. Employee #6 acknowledged these findings during an interview.
Facility staff failed to document skin assessments on admission and weekly as required for a resident with multiple diagnoses. The first documented skin assessment occurred one year after admission when a bruise was observed. The ADON confirmed the need for better education on documenting skin assessments, and the DON acknowledged policy overlap.
Facility staff failed to provide a safe environment for residents and staff, as evidenced by the improper storage of oxygen tanks. During an environmental walkthrough, three out of 51 oxygen tanks were found loosely stored upright on the floor of the oxygen storage room, creating an unsafe environment. An employee present at the time acknowledged these findings.
Failure to Prevent Elopement of Resident with Dementia and Exit-Seeking Behaviors
Penalty
Summary
Facility staff failed to adequately monitor a resident with a known history of dementia and prior exit-seeking behaviors, resulting in the resident eloping from a secured third-floor unit. The resident, who had been assessed as moderately at risk for elopement and had documented patterns of wandering and exit-seeking, was able to leave the facility without staff awareness. The care plan for this resident included multiple interventions to address wandering and elopement risk, such as structured activities, reorientation strategies, and monitoring for triggers, but these interventions were not effectively implemented to prevent the incident. On the day of the incident, the resident exited the unit by following a dining services employee through a locked door and subsequently accessed the service elevator, which was not fob-protected at the time. The resident was able to reach the first-floor garage level and exit the building, eventually being found outside near a busy intersection by another employee. Staff interviews and surveillance footage confirmed that the resident was outside the facility for approximately 20 minutes before being escorted back inside. Multiple staff members, including the assigned CNA and nursing leadership, were unaware of the resident's absence until the following day, despite the resident's well-documented history of frequent wandering and exit attempts. Documentation and interviews revealed that staff were aware of the resident's behaviors, including packing belongings and attempting to leave, but did not implement one-to-one supervision or other effective measures to prevent elopement. The facility's failure to provide adequate supervision and secure the environment allowed the resident to leave the premises unsupervised, constituting a deficiency in accident prevention and resident safety. The incident was not reported to facility leadership or the DON until the day after it occurred, further highlighting lapses in communication and monitoring.
Failure to Develop and Implement Person-Centered and Discharge Care Plans
Penalty
Summary
Facility staff failed to develop and implement a person-centered care plan for two residents, resulting in deficiencies related to both clinical and discharge planning. For one resident with multiple diagnoses including dementia, osteoporosis, and a history of urinary tract infections, the medical record documented moderate cognitive impairment and symptoms of a swallowing disorder, such as coughing or choking during meals. Despite a speech therapy evaluation diagnosing dysphagia and providing specific recommendations and training forms for staff, there was no documented evidence of a care plan addressing the resident's dysphagia in the medical record. Interviews with facility staff confirmed that the care plan for this condition was not developed or discussed during interdisciplinary team meetings. In another case, a resident with diagnoses including malignant neoplasm of the lung, glaucoma, and muscle weakness was admitted for care and later discharged to a hospital for further chemotherapy treatment. The social services progress note indicated ongoing discharge planning, but the resident and family declined participation. Despite this, there was no documented evidence of a discharge care plan in the resident's record. Staff interviews confirmed that the discharge care plan was not completed because the resident and family did not wish to participate. These findings demonstrate that the facility did not ensure the development and implementation of comprehensive, person-centered care plans for residents with identified clinical needs and for those requiring discharge planning, as evidenced by the lack of documentation and staff acknowledgment of the omissions.
Failure to Document IDT Care Plan Reviews and Conferences After MDS Assessments
Penalty
Summary
Facility staff failed to provide documented evidence that the Interdisciplinary Team (IDT) reviewed or revised care plans or conducted care plan conferences after each Minimum Data Set (MDS) assessment for seven of twenty-one sampled residents. This deficiency was identified through observations, record reviews, staff interviews, and resident interviews. The lack of documentation was noted after both quarterly and comprehensive (annual) MDS assessments, as well as after significant changes in condition for several residents. For example, one resident with multiple diagnoses including osteoporosis, arthritis, dementia, and muscle weakness had no documented IDT review or care plan conference following two quarterly MDS assessments. Another resident with morbid obesity, heart disease, and breast cancer also lacked documentation of care plan reviews or conferences after three separate MDS assessments, despite being cognitively intact and able to confirm that care plan conferences were not conducted as required. Similarly, a resident with dementia, muscle weakness, and major depression had no evidence of care plan review or conference after four quarterly MDS assessments, and this was acknowledged by the Assistant Director of Nursing upon review. Additional findings included a resident who experienced a fall and subsequent hospital transfer, yet the care plan was not updated to reflect new interventions for the urinary tract infection or contusion sustained. Other residents with severe cognitive impairment, communication deficits, and chronic medical conditions also lacked documentation of care plan meetings following multiple MDS assessments, with only sporadic evidence of such meetings in the medical record. Staff interviews confirmed that the expected process was not consistently followed, and documentation was missing for required IDT meetings and care plan reviews.
Failure to Document Physician Responses to Pharmacist Medication Regimen Review Recommendations
Penalty
Summary
Surveyors identified that the attending physician failed to document responses to pharmacist-identified medication regimen irregularities for five of twenty-one sampled residents. The facility's policy requires that a licensed pharmacist conduct monthly medication regimen reviews (MRR) for each resident, with any identified irregularities reported to the attending physician, who must then document a review and any actions taken in the resident's medical record. However, for multiple residents, there was no evidence in the medical record of the physician's response to the pharmacist's recommendations, nor were the recommendations themselves consistently present in the records. For one resident with osteoporosis and shoulder pain, the pharmacist repeatedly requested clarification on the dosage of Diclofenac gel, but the physician did not document a response in the medical record for several months, despite eventually updating the order. Another resident with multiple chronic conditions had pharmacy consult notes referencing recommendations, but neither the recommendations nor the physician's responses were found in the medical record. Similar deficiencies were observed for a resident with dementia and osteoporosis, where pharmacy recommendations and physician responses were kept in a binder in the nursing office rather than in the resident's medical record, and the pharmacist was unsure if she had access to the full medical record. Additional cases included a resident with complex medication orders for hypertension, where the pharmacist requested clarification on Metoprolol dosing multiple times before receiving a delayed response from the physician, and another resident with polypharmacy risk, where neither the pharmacist's report nor the physician's response was documented in the record. Staff interviews confirmed that recommendations and responses were often stored outside the resident's medical record, and in some cases, could not be located at all. These findings demonstrate a pattern of noncompliance with the facility's own policies and regulatory requirements for documenting pharmacist recommendations and physician responses in the medical record.
Failure to Immediately Notify Physician and Administrative Staff After Resident Injury
Penalty
Summary
Facility staff failed to immediately notify administrative staff or the resident's physician after a resident accidentally spilled hot coffee on her chest and subsequently developed a blister. The resident, who had multiple diagnoses including dementia, muscle weakness, and a history of CVA with left side weakness, required set-up assistance with meals and had a moderately impaired cognitive status. The incident occurred when the resident attempted to drink coffee and spilled it on herself. Although the incident was documented, the assigned RN did not report it until several hours later, after noticing a blister had formed. The RN, who was working a double shift, admitted during an interview that she did not immediately inform anyone about the incident, stating that time got away from her. The evening shift supervisor confirmed that the RN reported the incident late and had not notified the DON or ADON, who were present at the time. The ADON also stated that she was not informed of the incident and that the RN should have reported it when it happened. Documentation confirmed that the RN had previously attended in-service training on timely reporting of incidents.
Failure to Timely Report Elopement Investigation Results
Penalty
Summary
Facility staff failed to report the results of an investigation into a resident elopement to the State Survey Agency within the required five working days. The resident involved had a documented history of dementia, syncope, anxiety, breast cancer, and a right foot fracture, and was assessed as being at moderate risk for elopement. Care plans and evaluations consistently identified the resident as an elopement risk, with interventions in place such as structured activities, reorientation strategies, and the use of a wanderguard device. On the day of the incident, the resident eloped from her assigned unit and was found outside the facility, walking along a busy intersection approximately 1,000 feet from the building. Documentation showed that staff were aware of the resident's wandering and exit-seeking behaviors, and that interventions had been implemented to address these risks. However, the facility's investigative packet lacked documented evidence of a full investigation into how the resident was able to leave the unit and reach the outside area. Although an incident report was submitted to the Department of Health, the facility did not provide the results of its investigation to the State Survey Agency within the required timeframe. During an interview, the Director of Nursing acknowledged the delay in submitting the follow-up investigation, stating that the facility was still trying to determine how the resident exited the building. This failure to timely report the investigation results constituted the deficiency.
Failure to Timely Report Investigation Results to State Agency
Penalty
Summary
The facility failed to report the results of all investigations to the State Survey Agency within 5 working days of the incident for three sampled investigations. In the first case, a resident with multiple diagnoses including dementia, CVA with left-sided weakness, and osteoporosis was found to have an acute mildly displaced fracture of the distal shaft of the ulna. The incident was documented, and an investigation was conducted, but there was no evidence that the results of the investigation were submitted to the State Agency as required. Interviews with staff confirmed the lack of documentation regarding the submission of the investigation results. In the second case, another resident with dementia, a pacemaker, and muscle weakness experienced a fall while attempting to transfer herself from a wheelchair to the toilet, resulting in multiple fractures. The incident was reported, and an investigation was conducted, but again, there was no documented evidence that the results of the investigation were provided to the State Agency. Staff interviews indicated that the investigation was handled by a previous DON, and current staff could not locate documentation of the required submission. The third case involved a resident with dementia, syncope, anxiety, breast cancer, and a right foot fracture who was identified as an elopement risk. The resident eloped from the facility and was found outside by a staff member. Although the incident was reported and an investigation was initiated, there was a delay in starting the investigation, and the documentation did not include a thorough account of how the elopement occurred. While initial and follow-up reports were submitted to the State Agency, the investigative packet lacked comprehensive documentation of the investigation's results.
Failure to Complete Required PASARR Screening for Long-Term Resident
Penalty
Summary
Facility staff failed to complete a Level I PASARR (Preadmission Screening and Resident Review) for one resident who remained in the facility for longer than 30 days. The initial Level I PASARR form indicated the resident's stay would be less than 30 days, and as a result, only Section A was completed, while the remaining sections, including the section on dementia, were left blank. The resident in question was admitted with multiple diagnoses, including dementia, bipolar disorder, major depressive disorder, and anxiety, and was assessed as severely cognitively impaired according to a recent MDS assessment. Despite the resident's extended stay and significant mental health diagnoses, the required updated PASARR screening was not completed as mandated.
Physician Failed to Review and Reconcile Medication Orders During Required Visits
Penalty
Summary
A deficiency occurred when the physician failed to review and reconcile a resident's total program of care, including medications and treatments, during multiple required visits. The resident, who had diagnoses including dementia, hypertension, and generalized muscle weakness, had several changes to their Metoprolol orders over a period of several months. Despite these changes, there was no documented evidence that the physician reviewed or clarified the medication orders during at least five separate physician visits. The physician's notes often listed outdated medication regimens and did not address new or modified orders, resulting in discrepancies between the active orders in the electronic health record and the medication lists documented during visits. The facility's records showed that the resident received Metoprolol in varying doses and frequencies, with special instructions that were inconsistent with the total daily dose prescribed. Pharmacy consult notes repeatedly requested clarification of the Metoprolol orders, but the physician did not respond to these recommendations in a timely manner. The pharmacist reported making multiple attempts to obtain clarification, with no documented physician response until several weeks after the last recommendation. During this period, the medication administration records indicated that staff continued to administer Metoprolol according to orders that contained conflicting instructions. Interviews with the medical director confirmed that she was responsible for reviewing all medications and treatments during her visits and that she had changed the resident's Metoprolol dose several times. However, she did not provide an explanation for the lack of order clarification after each dose change. The lack of timely review and reconciliation of medication orders, as well as delayed responses to pharmacy recommendations, contributed to ongoing discrepancies in the resident's medication regimen.
Failure to Ensure Nurse Competency in Medication Order Transcription and Administration
Penalty
Summary
Facility staff failed to ensure that all licensed nurses possessed the necessary competencies and skills to accurately transcribe and administer medication orders for a resident with multiple complex diagnoses, including dementia, convulsions, hypertension, affective mood disorder, anxiety disorder, difficulty in walking, and generalized muscle weakness. The resident had a series of physician orders for Metoprolol Succinate ER, with specific instructions regarding dosage and administration, including holding the medication for certain blood pressure and heart rate thresholds. On multiple occasions, a charge nurse inaccurately transcribed new medication orders into the electronic health record by using the 'update' function, which automatically carried over special instructions from discontinued orders, resulting in erroneous directions to administer Metoprolol 25 mg alongside Metoprolol 50 mg, even after the 25 mg order had been discontinued. This transcription error led to the continued administration of both Metoprolol 50 mg and 25 mg together for a total daily dose of 75 mg, as documented in the medication administration records from November through early February. The error persisted because the special instructions from the discontinued order were not removed and were included in subsequent orders, and staff continued to follow these instructions as they appeared in the MAR. The charge nurse responsible for the transcription acknowledged the error and stated that she was unaware that using the 'update' button would carry over previous special instructions into new orders. Interviews with facility staff revealed that the process for transcribing physician orders involved both paper and electronic records, with the expectation that old orders would be discontinued before entering new ones. However, the practice of using the 'update' function in the electronic health record system led to the perpetuation of outdated instructions. Staff also indicated that nurses are expected to review the MAR for special instructions and to clarify discrepancies with the pharmacy or physician before administering medications, but this did not occur in this instance, resulting in the ongoing administration of an incorrect medication regimen.
Failure to Properly Label Opened Multi-Dose Medication
Penalty
Summary
Facility staff failed to ensure that a resident's medication was properly labeled in accordance with facility policy and professional standards. During an observation of medication storage, an opened multi-dose bottle of a liquid supplement, ProSource, was found in a resident's medication drawer without a date opened sticker. The bottle was nearly empty, and there was no indication of when it had been initially opened by staff. The pharmacy label on the bottle included the resident's name, room number, and physician's order, but did not fulfill the requirement for dating the container upon opening. The facility's policy requires that when the original seal of a manufacturer's container is broken, staff must place a date opened sticker on the medication and enter both the date opened and the new expiration date. The resident involved had multiple diagnoses, including dementia, seizures, dilated cardiomyopathy, and hypertension, and was assessed as severely cognitively impaired. The medication administration record showed that the supplement was being administered as ordered, but the lack of proper labeling was confirmed during staff interview.
Sanitation and Food Storage Deficiencies in Dietary Services
Penalty
Summary
Facility staff failed to maintain sanitary conditions in food preparation and distribution areas, as evidenced by multiple deficiencies observed during a survey. In the east-wing kitchen, an open and expired eyewash solution was found, and the dishwashing machine was leaking on both sides during operation. The handwashing sink in this area lacked disposable paper towels. In the west-wing kitchen, the paper towel dispenser above the handwashing sink was broken, another expired eyewash solution was present, and there was no handwashing soap available. Additionally, dust and foreign substances were observed on the wire guards for air condenser fans and the ceiling inside the walk-in refrigerator, as well as on a grate cover above the hot food holding and cook line areas in the main kitchen on the fourth floor. Further, improper food storage was identified in the main kitchen's walk-in refrigerator, where packages of ready-to-eat chopped celery, diced onions, and diced carrots showed signs of spoilage, including discoloration, texture changes, and leaking liquid accumulating in the holding pan. These findings were acknowledged by a facility employee during a face-to-face interview. No information about residents' medical history or condition at the time of the deficiency was provided in the report.
Failure to Meet Minimum RN Staffing Ratios
Penalty
Summary
The facility failed to comply with State Regulation 22B DCMR section 3211.5 regarding daily staffing ratios, specifically the requirement for a minimum daily average of at least 0.6 hours of resident care per resident by a Registered Nurse (RN). A review of the facility's daily staffing sheets showed that on seven out of forty-three sampled days, the RN staffing hours fell below the required minimum. On these days, the number of RN care hours provided per resident ranged from 0.2 to 0.5, despite resident census numbers between 27 and 30. During a face-to-face interview, the Director of Nursing was informed of the staffing shortfalls and acknowledged the findings. The report does not mention any specific residents affected or their medical conditions at the time of the deficiency, nor does it provide details about the impact on resident care during the periods of insufficient RN staffing.
Dishwashing Machine Not Maintained in Safe Working Condition
Penalty
Summary
Facility staff failed to maintain essential kitchen equipment in good working condition, as observed during a walkthrough of the east wing kitchen. The only dishwashing machine in that area was found to be spurting water solution from both sides during the wash and rinse cycles. This malfunction was directly observed by surveyors and later acknowledged by an employee during an interview. No information about residents or their medical conditions was provided in relation to this deficiency.
Failure to Maintain Effective Pest Control Program in Kitchen Area
Penalty
Summary
Facility staff failed to maintain an effective pest control program, as evidenced by the observation of flying insects around a handwashing sink in the east-wing kitchen. This deficiency was identified during an observation conducted at approximately 9:00 am, where the presence of flying insects was directly noted. During a subsequent interview, a staff member confirmed that the facility receives regular pest extermination services from a professional company and acknowledged the findings of the observation. No information regarding residents' medical history or condition was provided in relation to this deficiency.
Lack of Collaborative Hospice Care Plans
Penalty
Summary
The facility staff failed to ensure that residents had collaborative hospice care plans between the hospice agency and the facility. This deficiency was identified for five residents who did not have person-centered hospice care plans that included a description of the care, services, and frequency of visits to be provided by the contracted hospice provider. The medical records of these residents lacked the most recent hospice plans of care, and there was no documented evidence of collaboration between the facility staff and the hospice staff. Resident #13 was admitted with diagnoses including Dementia, Atrial Fibrillation, Hypothyroidism, and Anemia. Despite being on hospice care, the facility staff did not have a detailed hospice care plan that included the most recent hospice plan of care. Similarly, Resident #17, who had multiple diagnoses including Cerebral Infarction and Parkinson's Disease, did not have a collaborative hospice care plan that described the care, services, and frequency of visits. The hospice caregiver's visits and care were not adequately documented or aligned with the facility's care plan. Resident #27, admitted with diagnoses including a fracture of the neck of the left femur and severe dementia, also lacked a current written hospice care plan. The medical record did not show any collaboration between the facility and hospice staff. Resident #21, with diagnoses including unspecified dementia and heart disease, had a hospice care plan that did not include the frequency of hospice visits or collaborative interventions. Lastly, Resident #16, admitted with diagnoses including unspecified dementia and a fracture of the left femur, did not have a hospice care plan that documented the frequency of hospice visits or collaborative care between the facility and hospice staff.
Failure to Notify Residents of Account Balances
Penalty
Summary
Facility staff failed to notify Medicaid residents when the amount in their account reached $200 of the SSI resource limit. This deficiency was identified for two residents, who had balances of $4,296.15 and $4,497.67 respectively, as per the facility Trial Balance record dated 11/03/23. The failure to notify the residents or their Power of Attorney (POA) was confirmed during interviews with the Director of Nursing, who could not provide evidence of notification letters being sent or received by the residents or their POAs. The Director of Nursing acknowledged the findings when a copy or receipt of the notification letter was not presented to the surveyor. This lack of notification could potentially affect the residents' eligibility for Medicaid, as they were not informed that their account balances had reached within $200 of the SSI resource limit. The facility's inaction in this regard constitutes a failure to comply with the regulatory requirement to notify residents or their POAs about their account balances in a timely manner.
Inadequate Surety Bond Coverage for Resident Funds
Penalty
Summary
The facility staff failed to provide adequate surety bond coverage to assure the security of all residents' personal funds deposited with the facility. A review of the Surety Bond dated 05/06/23, with an expiration date of 05/06/24, revealed that the bond amount was $100,000.00. However, the Resident Funds Trust Account statements for August 2023 to October 2023 showed balances exceeding this amount, with totals of $123,976.18, $124,237.60, and $124,359.08, respectively. During a face-to-face interview on 12/07/23, an employee acknowledged the findings, confirming that the facility did not maintain a surety bond to cover the total amount of funds in the resident funds account for the specified period.
Failure to Notify Responsible Party of Resident's Condition Changes
Penalty
Summary
The facility staff failed to notify Resident #2's responsible party of significant changes in the resident's medical status and an unwitnessed fall. On 12/01/22, the resident was found to have an open and discolored sacral area, and although the medical doctor and a family member were notified, there was no documented evidence that the resident's Guardian/Power of Attorney was informed. Similarly, on 01/29/23, the resident was found sitting on the floor after an unwitnessed fall, and again, there was no documented evidence that the Guardian/Power of Attorney was notified, despite the facility's policy requiring such notification within 24 hours of a change in the resident's condition or status. Interviews with the resident's Power of Attorney for Medical Care and Guardian confirmed that the facility had not communicated changes in the resident's condition. The Director of Nursing also acknowledged that the charge nurse should have contacted the resident's Power of Attorney or responsible party, but it was not documented in the resident's notes. This lack of communication and documentation represents a deficiency in the facility's adherence to its own policies regarding notification of changes in a resident's condition.
Failure to Conduct Thorough Investigation into Resident's Fall
Penalty
Summary
The facility staff failed to implement its written policies and procedures for allegations of potential abuse and neglect by not conducting a thorough investigation into a resident's unwitnessed fall. The incident involved a resident with multiple diagnoses, including an unspecified fracture of the right femur and repeated falls. On the date of the incident, the resident was found lying on the floor in her room, and although a head-to-toe assessment was conducted and the resident was transferred to the hospital for further evaluation, the facility did not provide documented evidence of a thorough investigation into the fall. The facility's policies required that all accidents or incidents involving residents be documented on an Accident/Incident Report Form and that a thorough investigation be conducted for any suspected abuse, neglect, or injury of unknown source. However, the investigation into the resident's fall consisted only of the intake submitted to the State Agency and a brief document titled Incident Investigation, which included only one staff member's encounter with the resident after the fall. Interviews with facility staff confirmed that the investigation was incomplete and acknowledged the findings of the deficiency.
Failure to Conduct Thorough Investigation into Resident's Fall
Penalty
Summary
The facility staff failed to conduct a thorough investigation into an unwitnessed fall involving a resident. The resident, who had multiple diagnoses including unspecified fracture of the right femur and repeated falls, was found lying on the floor in her room. The incident was reported to the state agency, and the resident was transferred to the hospital for further evaluation. However, the facility's incident investigation only documented one staff's encounter with the resident after the fall and lacked comprehensive details about the investigation process. During interviews, the Registered Nurse Supervisor and the Director of Nursing acknowledged that the investigation was incomplete. The facility was unable to provide documented evidence that a thorough investigation was conducted, as required by their policies on accident and incident reporting and abuse, neglect, exploitation, or misappropriation reporting and investigating.
Failure to Provide Written Notice of Bed Hold Policy
Penalty
Summary
The facility staff failed to provide written notice of the bed hold policy to a resident or their responsible party upon transfer to the emergency room. Resident #135, who had multiple diagnoses including an unspecified fracture of the right femur and repeated falls, was observed lying on the floor in her room and was subsequently transferred to the hospital for further evaluation. The medical record review revealed no documented evidence that the facility staff provided the required written notice specifying the proposed action, reason for transfer, date of transfer, resident's destination, and the bed hold policy when the resident was transferred to the emergency room. During a face-to-face interview, the Director of Nursing acknowledged the findings. The incident was documented in a Facility Reported Incident submitted to the State Agency, and the medical record included notes about the resident's condition and the physician's order for transfer. However, the lack of written notice to the resident or their responsible party regarding the bed hold policy constitutes a deficiency in compliance with regulatory requirements.
Failure to Accurately Code Hospice Services on MDS Assessment
Penalty
Summary
Facility staff failed to accurately code a resident for hospice on a quarterly Minimum Data Set (MDS) assessment. Resident #21, who was admitted with multiple diagnoses including Unspecified Dementia, Bipolar Disorder, and Heart Disease, had an informed consent form signed for hospice services and a physician's order to admit the resident to hospice. Despite this, the MDS assessment indicated that the resident was not receiving hospice services. A review of the medical record showed no evidence that hospice services had stopped, and an employee confirmed that hospice should have been checked on the MDS assessment.
Failure to Update Care Plan for Use of Palm Protectors
Penalty
Summary
Facility staff failed to update and revise the care plan for a resident with severely impaired cognition and multiple diagnoses, including osteoarthritis and bilateral hand contractures. The resident was admitted with a physician's order to wear palm protectors for 4-5 hours a day. Observations by the surveyor confirmed that the resident was using the palm protectors as prescribed. However, a review of the resident's care plan, initiated on 09/24/21, showed no documented evidence that the care plan had been updated to include the use of palm protectors for both hands. During an interview, the Assistant Director of Nursing acknowledged that the care plan had not been updated to reflect the resident's use of palm protectors. The Treatment Administration Records from 11/28/23 to 12/08/23 documented that the resident was wearing the palm protectors for 4-6 hours a day, but this information was not reflected in the care plan. This oversight indicates a failure to provide resident-centered goals and update the care plan accordingly.
Failure to Provide Adequate Supervision and Safe Environment
Penalty
Summary
Facility staff failed to provide adequate supervision consistent with Resident #11's needs, goals, and care plan to reduce the risk of an accident, subsequently resulting in an unwitnessed fall. The resident, an 89-year-old male with Alzheimer's Dementia and a history of repeated falls, was admitted to the facility with multiple diagnoses including hip fractures and muscle weakness. Despite being identified as a high fall risk and requiring total dependence on staff for mobility and transferring, the resident was left unattended, leading to a fall while attempting to transfer from his wheelchair to his bed. The incident occurred on 11/27/23, and subsequent observations revealed that the resident continued to be left alone, even though his care plan explicitly stated that he should not be left unattended. Facility staff also failed to ensure that Resident #22, who was identified as having a high fall risk on admission, received adequate supervision to prevent injury of unknown origin. The resident, admitted with diagnoses including acute respiratory failure and Alzheimer's disease, was found with discoloration on her right eyelid and a raised area around her eyebrow. The injury was discovered on 12/1/22, and the resident was subsequently transferred to the emergency room for further evaluation. The investigation into the incident concluded that the etiology of the trauma was uncertain, and it was classified as an injury of unknown origin. Additionally, the facility failed to provide an environment free from accident hazards, as evidenced by three of 51 oxygen tanks being unsafely stored in the oxygen storage room. During an environmental walkthrough on 12/1/23, the oxygen tanks were found loosely stored upright on the floor, presenting an accident hazard. This observation was acknowledged by a facility employee present at the time.
Failure to Reconcile and Document Controlled Substances
Penalty
Summary
The facility staff failed to show documented evidence of reconciling a resident's prescribed controlled substance medication with the pharmacy delivery staff on multiple occasions. Specifically, for Resident #27, the facility did not ensure that both the nurse and the delivery person from the pharmacy signed the delivery sheets for Fentanyl patches. The review of the pharmacy delivery sheets revealed that only one nurse signed each delivery sheet, with no signature from the pharmacy delivery person, indicating that the controlled substances were not counted and verified by both parties as required by the facility's policy on controlled substances. Additionally, the facility staff failed to record the receipt of controlled substance medication on the narcotic medication reconciliation log for Resident #27. The review of the medication reconciliation form showed that the actual amount of Fentanyl patches delivered was not recorded in the specified section of the form on multiple dates. This lack of documentation was acknowledged by the Director of Nursing during an interview. Furthermore, the facility staff failed to account for the receipt, usage, disposition, and reconciliation of controlled medications on one of the nursing units. The review of the shift count narcotic records showed that the same nurse signed the shift narcotic count sheet as both the nurse coming on duty and the nurse going off duty on multiple occasions. This practice did not adhere to the facility's policy, which requires a physical inventory of all controlled substances to be conducted by two licensed nurses at each shift change or when keys are transferred.
Failure to Acknowledge Pharmacist's Medication Regimen Review Recommendations
Penalty
Summary
Facility staff failed to acknowledge and/or respond to the pharmacist's medication regimen review recommendations for two residents. Resident #6, who was admitted with multiple diagnoses including Cerebral Infarction, Chronic Obstructive Pulmonary Disease, Hypertension, Diabetes Mellitus, Anxiety Disorder, and Major Depressive Disorder, had no documented pharmacy recommendations or rationale of action taken by facility staff for the medication regimen review dates of 02/18/23, 05/16/23, and 11/21/23. Despite attempts by the Director of Nursing to locate these recommendations, they were not found in the resident's medical record. Similarly, Resident #25, admitted with diagnoses such as Encounter for Palliative Care, Urinary Tract Infection, Acute Embolism and Thrombosis, Dementia, Osteoporosis, Pulmonary Edema, Anxiety, and Depression, had no documented evidence that the physician responded to or reviewed the pharmacist's recommendations for the medication regimen review dates of 07/17/23 and 08/10/23. The Director of Nursing acknowledged the absence of these documents in the resident's medical record after failing to obtain them from the pharmacy.
Significant Medication Error Involving Fentanyl Patches
Penalty
Summary
The facility staff failed to ensure that a resident was free from significant medication errors, as evidenced by the resident being observed with three Fentanyl patches on at once. The resident, who had multiple diagnoses including a severe unspecified dementia and a fracture of the neck of the left femur, was found unrousable by her daughter. The daughter informed the Assistant Director of Nursing (ADON), who then evaluated the resident. A review of the physician's order indicated that only one Fentanyl patch should be applied every 72 hours and removed per schedule. However, the medication administration record showed that staff administered the Fentanyl patch and removed the previous one as scheduled, which was contradicted by the actual observation of three patches on the resident's body. Employee #11, a registered nurse, confirmed in a handwritten witness statement and a face-to-face interview that she observed three Fentanyl patches on the resident and removed two of them. The Director of Nursing (DON) later stated that the facility's investigation revealed that the Fentanyl patch was not removed on a specific date, leading to the accumulation of patches. The resident's relative also confirmed the observation of three patches without date or time markings. This incident was documented in a Facility Reported Incident (FRI) submitted to the State Agency, highlighting a significant medication error due to the failure to follow proper medication administration procedures.
Expired Food Items in Kitchen
Penalty
Summary
Facility staff failed to store and distribute food under sanitary conditions, as evidenced by the presence of expired food items. During a walkthrough of dietary services, surveyors observed that six out of six 5.5 fluid ounces of V8 vegetable drinks stored in the kitchen on the East side of the facility were expired. Additionally, six out of eight 5.5 fluid ounces of V8 vegetable drinks stored in the kitchen on the [NAME] side of the facility were also expired. Employee #6 acknowledged these findings during a face-to-face interview.
Failure to Document Skin Assessments and Changes in Skin Condition
Penalty
Summary
Facility staff failed to show documented evidence that skin assessments were completed on admission and weekly per the facility policy and physician's order for a resident with multiple diagnoses, including dementia and muscle weakness. The resident was admitted with a physician's order to complete a second-day admission skin evaluation and weekly skin assessments. However, there was no documented evidence of these assessments being completed as required, and the first documented skin assessment occurred one year after admission when a bruise was observed on the resident's left shin. The facility's policy required skin assessments to be conducted as soon as possible after admission and repeated weekly for the first four weeks, or as often as required based on the resident's condition. Despite this, the resident's medical record showed no weekly skin assessments until a bruise was noted, and no additional weekly assessments were documented after that date. The facility's Assistant Director of Nursing (ADON) confirmed that weekly skin assessments should be done for all residents and acknowledged the need for better education on documenting skin assessments. Additionally, the facility staff failed to record the resident's skin discoloration accurately on the Documentation Survey Report. The resident's medical record indicated that the bruise was observed and reported, but the Documentation Survey Report incorrectly documented 'None of the above observed' for the day, evening, and night shifts on the same day the bruise was reported. The Director of Nursing (DON) acknowledged the policy overlap and the need for adherence to the weekly skin assessment policy.
Unsafe Storage of Oxygen Tanks
Penalty
Summary
Facility staff failed to provide a safe environment for residents and staff, as evidenced by the improper storage of oxygen tanks. During an environmental walkthrough on the [NAME] side of the facility on December 1, 2023, at approximately 8:45 AM, three out of 51 oxygen tanks were found loosely stored upright on the floor of the oxygen storage room, creating an unsafe environment. Employee #3, who was present at the time of observation, acknowledged these findings during a face-to-face interview at approximately 9:00 AM on the same day.
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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