Inspire Rehabilitation And Health Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 2131 O Street Nw, Washington, District Of Columbia 20037
- CMS Provider Number
- 095031
- Inspections on file
- 19
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 20
Citation history
Health deficiencies cited at Inspire Rehabilitation And Health Center Llc during CMS and state inspections, most recent first.
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.
A resident with multiple complex conditions, including fluid overload, dementia, heart failure with reduced EF, and a necrotic heel ulcer, was transferred to the ER for hypotension, fever, and altered mental status after a physician ordered emergency transfer and 911 was called. The hospital was later listed as the resident’s discharge location, and the care plan was closed with the reason noted as discharge. However, the record contained no documented discharge planning or additional information related to discharge planning after hospitalization, and the DON acknowledged the resident was discharged without a documented discharge reason and location, resulting in a deficiency related to discharge planning and safe transfer/discharge preparation.
A resident with multiple medical conditions and a BIMS score indicating some cognitive impairment had an MDS goal of discharge to the community and verbally expressed a strong desire to leave and have an indwelling catheter removed. Although the Social Services Director and DON stated that discharge planning begins at admission, is discussed in IDT meetings, and should be documented in EMR progress notes, the record lacked any documented discharge plan, anticipated discharge destination, post-discharge services, or documented communication with the resident about discharge planning. A social services note from an IDT meeting recorded the resident’s mood and orientation but did not include discharge planning details, despite an application reportedly being submitted to the Department of Aging for assisted living placement.
Staff failed to accurately code a resident’s opioid use on a quarterly MDS assessment. A resident with multiple chronic conditions, including CVA, epilepsy, type 2 DM, vascular dementia, and schizophrenia, had physician orders for Tramadol 50 mg PO every 8 hours for pain over several months, and MAR review confirmed regular administration for low back pain. However, the quarterly MDS documented use of an antidepressant, anticoagulant, hypoglycemic, and anticonvulsant, but did not indicate opioid use, which the MDS coordinator later acknowledged had been overlooked.
A resident admitted with Bipolar Disorder, neurosyphilis, and significant functional impairments was cognitively intact per MDS and exhibited mood symptoms such as depression and low energy. The care plan identified Bipolar Disorder with a goal of mood stability, and ePASARR submissions showed a positive screen for serious mental illness, yet no PASARR Level II evaluation was documented. The Social Services Director reported not handling PASARR screenings and assuming the psychiatric vendor completed the process, while the Business Office Manager described relying on a psychiatric evaluation and an outside company to determine Level II need. The resident was observed in bed, expressing boredom, unhappiness with the stay, and frequent anger about life.
Surveyors found that the facility failed to develop a care plan for a cognitively intact resident’s documented tuna and Motrin allergies and did not implement existing care plan interventions for another cognitively intact resident’s dentures. One resident reported a tuna allergy and believed she was receiving tuna-containing food, yet her comprehensive care plan contained no allergy interventions despite documented allergies in the medical record. Another resident with multiple comorbidities and impaired upper extremity function had physician orders and a care plan directing staff to assist with denture placement, removal, cleaning, and fit checks, but she was repeatedly observed without dentures, reported they were painful and ill-fitting, and an evening-shift CNA was unaware she had dentures, indicating that ordered and care-planned denture interventions were not being carried out.
Facility staff did not consistently provide or document weekly 1:1 activity sessions for a bed-bound, cognitively intact resident with significant physical limitations and multiple medical conditions, despite a care plan requiring staff-dependent activities, cognitive stimulation, and social interaction. Documentation over a one-month period showed only two 1:1 sessions and a few brief social contacts that did not reflect structured activities as care planned. The activities calendar was posted but not effectively communicated, as the resident reported not knowing it was in the room or understanding the activities process and learning of at least one event only from a CNA. The Activities Director and DON stated that residents unable to attend group activities should receive weekly bedside or 1:1 activities and reminders about scheduled events, but records did not demonstrate that this occurred for the resident.
Staff failed to follow physician orders and care plan interventions for two residents. For one resident with upper extremity contractures, staff left a left elbow extension splint on significantly longer than the ordered wear time, and the restorative aide was unaware of the specific duration and did not document splint removal. For another resident with dysphagia, multiple comorbidities, and documented need for substantial assistance with oral hygiene, staff were ordered and care planned to assist with denture placement, removal, fit checks, and cleaning, yet the resident was repeatedly observed without dentures, reported that they hurt and did not fit, and stated no one had arranged a dental appointment. Treatment records nonetheless reflected that staff had performed the ordered denture care, and a CNA reported not knowing the resident had dentures, while the unit manager was unaware of any denture issues until directly informed by the resident.
The facility failed to ensure consistent monthly medication regimen reviews and timely implementation of pharmacist-identified irregularities for multiple residents receiving complex and psychotropic drug therapies. For several residents with dementia, schizophrenia, and multiple comorbidities, required monthly MRRs were missing for multiple months, and prescriber responses to pharmacist-identified irregularities were incomplete, often limited to agreement without documented actions. For a resident using diclofenac (Voltaren) gel, the consultant pharmacist twice recommended specific dosing parameters, but these were not incorporated into the MAR or the initial provider order, and the recommendations were not promptly uploaded into the EMR. The DON and an NP acknowledged gaps in reviewing, documenting, and acting on pharmacy recommendations as part of the facility’s MRR process.
Surveyors found that the facility did not ensure appropriate competencies for food and nutrition service staff when the kitchen food service manager was working without a valid certified food protection manager identification card issued by the local health department. During an interview, the food service manager and the nutritionist acknowledged that this required certification was not in place.
Surveyors identified multiple food service deficiencies, including unclean interior surfaces of ice machines, lack of hand-washing soap at a kitchen hand sink, improper hot-holding of cooked chicken at 122°F on a steam table, and melted commercially packaged chocolate ice cream stored in ice. The dishwashing machine used a bleach-based sanitizer without appropriate test strips to verify concentration, and staff personal belongings were stored on top of emergency bottled water cases. These conditions were observed and acknowledged by food service and maintenance staff.
Facility staff did not ensure that residents and their representatives understood binding arbitration agreements included in the admission packet. Several cognitively intact residents and representatives, including individuals with multiple sclerosis, hemiplegia after stroke, rib fracture, heart failure, and other conditions, reported they did not recall signing arbitration documents, did not understand that signing waived their right to pursue court action, and were not clearly advised to seek legal counsel or informed of the legal implications. The admissions director stated she reviews the agreements after obtaining BIMS scores, explains that signing is voluntary and that disputes would go to the facility’s arbitrator, and tells signers they have 30 days to rescind, but her described rescission process differed from the written requirement in the document, and she relied on simply asking if they understood to assess comprehension.
Facility staff used a binding arbitration agreement in the admission packet that required disputes about services or health care to be resolved exclusively by arbitration but did not include language that a neutral arbitrator, mutually agreed upon by both parties, would be selected or that the arbitration venue would be convenient to both parties. Several residents with conditions such as multiple sclerosis, hemiplegia after CVA, CHF, cognitive communication deficits, and other comorbidities, or their representatives, signed these agreements while having intact cognition documented on MDS assessments in some cases. In interviews, residents and their representatives consistently reported that admission staff did not explain that they could participate in selecting a neutral arbitrator and a neutral, convenient arbitration location, and the Admissions Director confirmed that such language was not included in the agreement.
Staff did not implement appropriate infection control measures during a cluster of residents with nausea and vomiting consistent with Norovirus, leaving symptomatic residents in semi‑private rooms with unaffected roommates despite available empty rooms, and one roommate later became ill after cohorting with a symptomatic resident. During a breakfast meal service, a CNA passed and set up trays, handled food items, and provided feeding assistance to three residents in succession without performing hand hygiene between residents or after contact with their environment, contrary to the facility’s hand hygiene policy. The facility also failed to complete an annual review of two COVID‑19–related infection control policies, including resident vaccination and PPE/source control for healthcare personnel, with the infection preventionist acknowledging that policy updates were awaited from a regional office.
Surveyors found that kitchen equipment was not maintained in safe operating condition, including a nonfunctional pressure gauge on the automatic dishwasher, a leaking backflow preventer valve, and water spraying from the dishwashing machine that staff attempted to contain with plastic bags. The spray hose was stored below the floor rim level on the garbage scrap board without a hook or hanger to keep it above the flood rim, and a condensate drainpipe from an overhead AC unit was routed through a ceiling tile to drain into the garbage disposer sink. These conditions were observed and acknowledged by the food service manager and maintenance director.
Staff failed to maintain an effective pest control program when a dead cockroach was observed on the floor of the kitchen dry storage room during a survey. Pest control reports from the contracted extermination company for prior visits documented no cockroach activity in the kitchen, despite the later observation. The Food Service Manager, Maintenance Staff, and the Administrator acknowledged the pest finding and confirmed that a professional pest exterminator services the facility on a biweekly and as-needed basis.
Facility staff did not develop a comprehensive care plan with goals and interventions for a resident who was admitted with multiple neurologic and medical conditions, including hemiplegia, gastrostomy status, and aphasia, and who had an indwelling Foley catheter in place for obstructive uropathy. Documentation at admission, in the MDS, and in physician orders confirmed ongoing Foley catheter use, and the resident was observed in bed with the catheter to bedside drainage. Record review showed no care plan addressing the catheter, and the DON acknowledged that after an early care plan meeting, staff failed to create a specific care plan for the resident’s Foley catheter.
Staff failed to prevent a significant medication error when a hospice resident who was NPO with a non-functioning G-tube had a morphine sulfate concentrate order transcribed and maintained on the MAR with an oral route, despite being unable to take anything by mouth. The admitting nurse entered the order, and a unit manager/LPN completed a 24-hour chart check but did not question or correct the route. The morphine was never administered, yet the incorrect oral route remained uncorrected by nursing, the dispensing pharmacy, the consultant pharmacist, or the Medical Director, constituting a near-miss medication error in the prescribing/transcribing process.
Staff failed to follow infection control policies for two residents on Enhanced Barrier Precautions (EBP). In both cases, clear signage at the room entrances directed staff to wear gloves and a gown for high-contact care activities such as bathing, dressing, hygiene, and toileting. One resident with a G-tube, Foley catheter, and wounds had a care plan and physician order specifying EBP, yet a CNA bathed the resident wearing only a mask and gloves, without a gown. Another resident with bilateral above-knee amputations and a Stage IV pressure ulcer received a bed bath and gown change from a CNA who wore gloves but no gown, despite acknowledging that proper PPE for EBP bathing includes both gown and gloves.
Facility staff failed to provide a clean, homelike environment for two residents. One resident's room had a dusty air conditioning unit and a sticky, stained over-bed table, while another resident's room had chipping paint and a large hole in the wall. The issues were acknowledged by the Director of Housekeeping and Laundry and the Director of Maintenance, respectively.
The facility failed to thoroughly investigate multiple allegations of abuse, neglect, and unusual occurrences involving five residents. Key incidents included uninvestigated allegations of inappropriate touch, verbal abuse, a fatal fall, a verbal altercation, and an unusual occurrence involving severe cognitive impairment. The facility's investigation packets were incomplete, and the DON confirmed that no investigations were conducted for some incidents.
The facility staff failed to report allegations of abuse and an unusual incident to the State Agency for two residents. One resident experienced a verbal altercation with another resident, and the facility did not investigate or report the incident. Another resident was transferred to the hospital with bruising and scratching, and the facility did not investigate or report the allegation of abuse. Additionally, the resident's daughter was observed trying to administer supplements without consulting the clinical team, and the facility did not investigate or report this unusual occurrence.
Facility staff failed to document corrective actions to protect a resident from potential abuse by an employee, did not investigate a resident's report of a verbal altercation, and neglected to investigate abuse allegations and an unusual incident involving another resident.
Facility staff failed to provide two residents or their representatives with timely bed-hold notices upon hospital transfer. One resident with intact cognition and another with severely impaired cognitive function were transferred to the hospital, but the required notices were delayed or not provided, as acknowledged by the social worker.
Facility staff failed to accurately code the MDS assessments for two residents, missing a fall for one resident and a surgical wound for another. These inaccuracies were identified through record reviews and staff interviews, revealing gaps in the documentation of significant medical events and conditions.
Facility staff failed to implement a resident's care plan for the use of carrot palm guards to prevent skin integrity impairment and further immobility/contractures. The resident, who had severe cognitive impairment and was dependent on staff for all ADLs, was observed without the palm guards on multiple occasions. The resident's refusal to keep the guards on was not documented in the care plan, and the physician was not informed of the non-compliance.
Facility staff failed to ensure that a resident with limited range of motion received appropriate treatment to prevent further decline. The resident frequently removed prescribed palm guards, and this behavior was not communicated to the physician for alternative treatment. Observations showed the resident's hands were contracted, and staff inaccurately documented the application of the splints.
The facility staff failed to adequately supervise a resident while toileting, as required by the resident's MDS assessment. The resident experienced two falls while attempting to use the bathroom independently, despite needing supervision and a one-person assist. The medical record lacked evidence of proper supervision, and the Director of Nursing acknowledged the requirement for staff presence in the bathroom.
Facility staff failed to follow established procedures for the accurate reconciliation of narcotics. An LPN did not sign off the narcotic count for the 7:00 AM - 3:00 PM shift, stating she had to run to the bathroom during the count and forgot to sign off.
The facility failed to document the physician's review of pharmacy regimen reviews for a resident with multiple diagnoses, including Dementia and Paranoid Schizophrenia. Despite several pharmacy reviews, the physician's responses were not in the resident's medical record, which was acknowledged by a QA employee during an interview.
Facility staff failed to store and label biologicals in accordance with professional practices. An opened Lantus vial was found without an open or expire date, and two Novolog pens were improperly labeled. LPNs acknowledged the findings and discarded the items.
Facility staff failed to ensure that the dishwasher reached the required temperature to clean dishes and utensils under sanitary conditions. During observations, the high temperature dishwasher reached a high of 130 and 132 degrees Fahrenheit, respectively. The Food Service Director acknowledged the findings and stated that the Maintenance Director would be notified.
The facility staff failed to ensure accurate documentation in the medical records of three residents, including incorrect fall documentation, failure to record a resident's death, inaccurate refusal of care documentation, and incorrect weekly skin assessments.
The facility failed to ensure that a resident had a current written hospice care plan, including the most recent hospice plan of care and a description of the care and services furnished by the LTC facility. The care plans had not been updated since June 29, 2023, and lacked specific details on the hospice provider's responsibilities.
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.
Failure to Develop and Document Discharge Planning for Hospitalized Resident
Penalty
Summary
Facility staff failed to develop and document effective discharge planning for a resident who was hospitalized and subsequently discharged from the facility. The resident had multiple diagnoses including fluid overload, hypertension, a right heel skin ulcer with muscle necrosis, dementia, heart failure with reduced ejection fraction, and iron deficiency anemia. On 01/23/2026 at 07:24, nursing notes documented that the resident was in bed, awake but hypotensive, febrile, with altered mental status and lethargy, though without shortness of breath or distress, and the physician ordered transfer to the nearest ER via 911, with the resident’s responsible party notified. Later that day, a progress note listed hospitalization with the hospital identified as the resident’s discharge location. The care plan review on 03/10/2026 showed the resident’s care plan was closed on 02/10/2026 with the reason marked as “discharged.” However, there was no documented evidence in the medical record of discharge planning or additional information related to discharge planning after the resident’s hospitalization, and during a face-to-face interview the DON stated the patient was discharged, while acknowledging there was no documented discharge reason with location for the resident’s discharge. These findings reflect that the facility did not ensure the transfer/discharge process met the resident’s needs and preferences or that the resident was prepared for a safe transfer/discharge, as required, due to the absence of documented discharge planning despite the resident’s hospitalization and discharge status in the record.
Failure to Initiate and Document Discharge Planning for Resident Desiring Community Discharge
Penalty
Summary
Facility staff failed to initiate and document discharge planning for a resident who had an expressed goal and desire to return to the community. The resident was admitted with multiple medical diagnoses, including urinary tract infection, epididymitis, hydronephrosis, muscle weakness, ureteral calculus, urinary retention, dysphagia (oral phase), gait abnormalities, obstructive and reflux uropathy, hypertension, hyperlipidemia, and adjustment disorder with mixed anxiety and depressed mood. An MDS dated with a specified assessment date showed a BIMS score of 12, indicating some cognitive impairment, and documented that the resident’s overall goal was discharge to the community. Despite this, review of the medical record showed no documented discharge plan outlining an anticipated discharge destination, needed post-discharge services, or coordination with community providers. During an interview, the resident clearly stated a desire to leave the facility and have his indwelling catheter removed. The Social Services Director reported that discharge plans are typically documented in progress notes and discussed during IDT meetings within 7–10 days of admission, and that discharge planning includes determining equipment needs, anticipated discharge date, and contacting community agencies. The Social Services Director also stated that an application had been submitted to the Department of Aging for assisted living placement and that communication with the resident about discharge planning had occurred, but acknowledged this was not documented. A social services progress note from an IDT meeting documented that the resident was alert, oriented, in a bad mood, and had no questions or concerns, but did not include any discharge plan, anticipated discharge location, or post-discharge services. The DON stated that discharge planning begins at admission and should be documented in the EMR under social services progress notes, yet the record contained no documented discharge plan or communication with the resident regarding discharge planning, despite the resident’s stated goal and desire to discharge to the community.
Inaccurate MDS Coding of Opioid Use
Penalty
Summary
Facility staff failed to accurately code a resident’s use of opioid medication on a quarterly MDS assessment. The resident was admitted with multiple diagnoses including hypertension, CVA with left-sided residual deficit, atrial fibrillation, parainfluenza, epilepsy, type 2 DM, vascular dementia, and schizophrenia. Physician orders documented continuous use of Tramadol HCl 50 mg PO every 8 hours for pain beginning in mid-November and continuing through at least early March, with only brief discontinuation and reordering, and MAR review confirmed that staff administered Tramadol 50 mg every 8 hours for low back pain during this period. Despite this ongoing opioid administration, the quarterly MDS listed the resident as receiving an antidepressant, anticoagulant, hypoglycemic, and anticonvulsant, but did not indicate that the resident was receiving opioids for pain. During an interview, the MDS Coordinator acknowledged that the omission of the opioid on the MDS assessment was an oversight.
Failure to Complete PASARR Level II Evaluation for Resident With Bipolar Disorder
Penalty
Summary
The deficiency involves the facility’s failure to ensure completion of a PASARR Level II evaluation for a resident with a documented diagnosis of Bipolar Disorder. The resident was admitted with multiple diagnoses, including Bipolar Disorder and neurosyphilis, and had significant functional impairments, including dependence in most self-care activities, wheelchair use for mobility, and total incontinence of bowel and bladder. A quarterly MDS assessment showed a BIMS score of 15, indicating the resident was cognitively intact and able to participate in care planning, and documented mood symptoms such as little interest or pleasure in doing things, feeling down or depressed, and feeling tired or having little energy. The care plan specifically identified Bipolar Disorder as a focus, with a goal of mood stability and an intervention for staff to encourage treatment and medication compliance. Despite these findings and the documented diagnosis of Bipolar Disorder at admission, the PASARR Level I screening dated 04/14/2025 indicated a negative screen for intellectual disability or related conditions and stated no further action was necessary. However, ePASARR submissions dated 05/21/2025 and 03/11/2026 documented a positive screen for serious mental illness and were submitted to the Department of Health Care Facilities, indicating a possible need for further evaluation. There was no evidence in the medical record that a PASARR Level II evaluation was ever completed. During interviews, the Social Services Director stated he does not complete PASARR screenings and believed the psychiatric company’s evaluation completed the PASARR process, while the Business Office Manager described a process in which a psychiatric doctor evaluates new admissions and, if a mental illness is identified, an ePASARR is filed and the outside company determines the need for Level II. The resident was observed on multiple occasions lying in bed, expressing boredom and unhappiness about being in the facility, and often expressing anger about life, but no corresponding PASARR Level II evaluation was documented.
Failure to Care Plan for Allergies and Implement Denture Care Interventions
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement comprehensive care plan interventions for a resident’s documented allergies and another resident’s denture use and oral care. One resident was admitted with multiple diagnoses, including urinary tract infection, convulsions, dysphagia, hypertension, acute kidney failure, hemiplegia and hemiparesis following cerebral infarction, acute embolism and thrombosis of deep veins of the lower extremity, muscle weakness, altered mental status, morbid obesity, and age-related nuclear cataract. The resident’s MDS showed a BIMS score of 14, indicating she was cognitively able to participate in care decisions. The physician history and physical documented allergies to Motrin and tuna, but review of the comprehensive care plan showed no care plan developed to address these allergies. During observation, this resident was lying in bed and stated she was allergic to tuna and believed the facility was providing her food containing tuna, which she associated with experiencing an allergic reaction and a rash on her face. She showed no signs of distress at the time of observation. Staff interviews revealed that the 1st floor RN unit manager believed the tuna allergy was listed on the resident’s meal ticket but needed to verify this with the food operations department. The dietician explained that residents’ food preferences are entered into an electronic dining system that generates meal ticket information, and that preferences are obtained during the initial assessment and baseline care plan and reviewed every three months, with documentation in the care plan and dietician notes. The RN charge nurse stated she had never heard the resident complain about food allergies but knew of the tuna allergy from completing the admission assessment. The DON stated that medication and food allergies should be assessed and documented during admission and later acknowledged that the resident should have a care plan addressing her allergies. The facility did not have such a care plan in place until after surveyor inquiry. The second part of the deficiency concerns another resident admitted with dysphagia following cerebral infarction, type 2 diabetes mellitus with diabetic autonomic polyneuropathy, heart failure, primary open-angle glaucoma, major depressive disorder, morbid obesity, and generalized muscle weakness. This resident was observed multiple times awake in bed watching television, with a denture cup at the bedside but not wearing dentures. The resident reported needing staff assistance with oral care and denture placement, stated that the dentures did not fit properly, caused pain, and that she had not been wearing them lately. She reported having received new dentures a few months earlier after losing her old ones and stated that the facility was aware of her concerns. Record review showed multiple physician orders for dental consults, denture care, and specific instructions to assist and encourage the resident to place and remove full upper and lower dentures, check denture fit while awake, and ensure dentures were rinsed and stored properly. The resident’s care plan documented impaired dentition related to using dentures, with goals for clean teeth and healthy gums and interventions including assessing and documenting the resident’s ability to perform dental care, assisting as needed, obtaining dental consults per policy and as needed, modifying diet as needed, monitoring oral intake, assisting and encouraging denture use during AM and PM care, checking denture fit, and checking linens and other areas if dentures were missing. A quarterly MDS showed intact cognition with a BIMS score of 15, upper extremity impairments, and a need for substantial/maximal assistance with oral hygiene, including denture management. The TAR for the review period documented that staff were carrying out the ordered denture-related interventions; however, observations on several dates showed the resident not wearing dentures and reporting that they hurt and that she had not worn them for months. An evening-shift CNA stated she did not know the resident had dentures and had never seen her wearing them. The RN unit manager confirmed the existence of a dental care plan with interventions to assist with dentures but stated she was not aware of any issues with denture fit until speaking directly with the resident, who reiterated that the dentures did not fit and were painful. These findings showed no evidence that staff implemented the resident’s dental care plan interventions.
Failure to Provide and Document Planned 1:1 Activities for a Bed-Bound Resident
Penalty
Summary
Facility staff failed to implement and document individualized 1:1 activity sessions as care planned for a cognitively intact, bed-bound resident with significant physical limitations and multiple medical conditions, including hemiplegia, osteomyelitis, a stage 4 sacral pressure ulcer, generalized muscle weakness, dysphagia, and malnutrition. The resident’s MDS showed dependence on staff for most ADLs, use of a wheelchair for mobility, and little interest or pleasure in activities. The care plan, revised on 03/05/2025, identified the resident as dependent on staff for activities, cognitive stimulation, and social interaction, with a goal for weekly participation in activities of choice. Interventions included inviting the resident to scheduled activities, providing 1:1 bedside or in-room activities if unable to attend group activities, providing an activities calendar and notifying the resident of changes, and having staff converse with the resident during care to encourage engagement. Surveyors’ review of activity task documentation from 02/05/2026 through 03/05/2026 showed only two documented 1:1 activity sessions, despite the care plan’s expectation for weekly participation. Progress notes from 02/02/2026 through 03/06/2026 contained limited entries from the activities department, such as brief social visits and mail delivery, and did not demonstrate consistent or structured 1:1 activity sessions as outlined in the care plan. Observations found the resident in bed or being transported for a medical appointment without signs of distress, and the activities calendar was posted on the wall behind the head of the bed. In an interview, the resident stated she was unaware the activities calendar was in her room, did not know the activities process, and learned of at least one event only when informed by a CNA. The Activities Director and DON both stated that residents with physical limitations who cannot attend group activities should receive weekly 1:1 or bedside activities and be reminded of activities, but the documented record did not show consistent provision or documentation of these 1:1 sessions for this resident.
Failure to Follow Splint and Denture Care Orders for Two Residents
Penalty
Summary
Facility staff failed to follow physician orders for splint placement for one resident with upper extremity contractures. The resident had dementia with psychotic disturbance, seizure disorder, a colostomy, and documented impairments in both upper and lower extremities. A physician’s order directed that the resident wear a left elbow extension splint on the left upper extremity for three hours, and the care plan required staff to check the extremity and skin beneath and adjacent to the splint regularly. On one observation day, the resident was seen in bed with the left arm splint in place in the morning and still in place several hours later in the afternoon, suggesting the splint remained on beyond the ordered three-hour period. In a later interview, the restorative aide/CNA reported that staff typically put the splint on between 7:00–8:00 a.m. and removed it between 1:00–2:00 p.m., and acknowledged that removal was not documented and that she was unaware of the specific ordered wear time for this resident. Facility staff also failed to consistently assist another resident with the application and management of dentures as ordered and care planned. This resident had multiple diagnoses including dysphagia following cerebral infarction, type 2 diabetes with autonomic neuropathy, heart failure, glaucoma, major depressive disorder, morbid obesity, and generalized muscle weakness, and required substantial/maximal assistance with oral hygiene and denture management per the MDS. Physician orders and the care plan directed staff to assist and encourage the resident to place full upper and lower dentures on during the day shift, remove them during the evening shift, check denture fit while the resident was awake, assist with washing dentures, and place them in a denture cup with tablet at bedtime, as well as to obtain dental consults per policy and as needed. Despite these orders and care plan interventions, multiple observations over several days showed the resident awake in bed without dentures in place. The resident reported that staff helped her rinse her mouth and put in dentures but that she had not been wearing them lately because they hurt and did not fit properly, and that she wanted new dentures to be able to eat other foods. She also stated that no staff had offered to schedule a dental appointment to address the fit issues. Review of the treatment administration records showed staff had documented that they were assisting with denture placement, removal, fit checks, and cleaning, even though the resident was repeatedly observed without dentures. A CNA on the evening shift stated she did not know the resident had dentures and had never seen her with them. The unit manager/RN confirmed there were physician orders and a dental care plan for dentures and stated she was not aware of any issues with denture fit until speaking directly with the resident, and acknowledged that no nursing staff had reported denture fit problems despite the existing orders and care plan.
Failure to Complete and Implement Monthly Medication Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a licensed pharmacist completed and the facility acted upon monthly drug regimen reviews (MRRs) as required, including timely reporting and implementation of identified irregularities. For one resident with chronic kidney disease, hypertension, diabetes mellitus, hyperlipidemia, osteoarthritis, dementia with psychotic disturbance, paranoid schizophrenia, depression, and anxiety, the pharmacist documented multiple MRRs over several months and recorded three irregularities. The prescriber’s responses were documented only as “I agree,” without specifying what actions would be taken to address the irregularities, and there was no evidence that the pharmacist’s drug regimen review was conducted every month. During an interview, the DON acknowledged both the lack of monthly reviews and the incomplete responses to the pharmacist’s documented irregularities. Another resident with dementia with psychotic disturbance, seizure disorder, and a colostomy was receiving memantine, quetiapine, and divalproex sodium for dementia with behavioral disturbances and agitation. The care plan included monitoring for side effects and effectiveness of psychotropic medications and communicating with the physician and family about ongoing need and potential adverse reactions. However, review of the medical record showed no documented evidence that monthly drug regimen reviews were completed for several specific months, despite the resident’s use of multiple psychotropic medications and the care plan’s emphasis on monitoring and review. A third resident with schizophrenia and psychotic disorder was prescribed aripiprazole and had care plans addressing psychotropic medication use and polypharmacy, including monitoring for adverse reactions and reviewing pharmacy consult recommendations. The record review revealed that monthly drug regimen reviews were missing for two identified months. The DON stated that MRR reports are received through a portal and distributed to unit managers for physician review and implementation, and that once providers agree with recommendations, they should be implemented and uploaded within about one week; however, the missing documentation showed this process was not consistently followed. For another resident with hemiplegia, type 2 diabetes mellitus, protein energy malnutrition, major depressive disorder, atrial fibrillation, hydronephrosis, urinary retention, urinary calculus, impaired cognition, wheelchair use, an indwelling urinary catheter, and a diabetic toe wound, the consultant pharmacist made specific recommendations in two separate MRRs to define the dose and dosing limits for diclofenac (Voltaren) gel. These recommendations included suggested gram amounts per application and maximum daily doses for upper and lower extremities and total body use. The MRRs were signed by the consultant pharmacist and the unit manager RN, but the medication administration record showed the gel was administered twice daily without the dosing parameters specified, and the initial physician order entered later also lacked the recommended dosing limits. The DON acknowledged that the pharmacy recommendations had not been uploaded into the electronic medical record as expected, and the nurse practitioner stated he inadvertently missed the pharmacist’s recommendations when prescribing the medication. These findings demonstrate that pharmacist-identified medication regimen irregularities were not consistently reported, acted upon, or implemented in a timely manner for multiple residents.
Food Service Manager Lacked Required Certified Food Protection Manager Credential
Penalty
Summary
Facility staff failed to employ food and nutrition service staff with appropriate competencies when the kitchen food service manager did not possess a valid certified food protection manager identification card issued by the DC Department of Health. During the initial kitchen survey conducted on 03/02/2026 at approximately 11:15 AM, surveyors observed that the food service manager lacked this required certification. In a face-to-face interview at the same time, the food service manager and the facility nutritionist both acknowledged that the food service manager did not have a valid certified food protection manager identification card.
Food Service Sanitation and Temperature Control Deficiencies
Penalty
Summary
Facility staff failed to prepare and distribute food under sanitary conditions and to store food at appropriate temperatures. During an initial kitchen survey, surveyors observed that the interior surfaces of the ice-making machines were not cleaned. In the food preparation area, the hand-washing sink lacked hand-washing soap in the wall-mounted dispenser. These conditions were observed in the kitchen and were acknowledged by the food service manager and the nutritionist. During a follow-up kitchen survey, surveyors observed additional food safety and sanitation deficiencies. Cooked chicken on the steam table was not held at a proper hot-holding temperature, with a digital probe thermometer reading 122°F. Commercially packaged chocolate ice cream cups stored in a bin with ice were observed melted. The automatic dishwashing machine was using a sodium hypochlorite (bleach) sanitizing chemical, but there were no appropriate test strips available to measure the concentration of the bleach solution. Employee personal belongings, including jackets and backpacks, were placed haphazardly on top of cases of bottled water stored for emergency purposes. These observations were acknowledged by the food service manager and maintenance staff.
Failure to Ensure Residents and Representatives Understood Binding Arbitration Agreements
Penalty
Summary
Facility staff failed to ensure that residents and/or their representatives understood the binding arbitration agreements included in the admission packet. The facility’s standard arbitration form stated that any disputes regarding services or health care provided by the facility would be resolved through binding arbitration, that signing the agreement waived statutory and constitutional rights to have claims decided in court before a judge and jury, and that signing was not a precondition for admission. The agreement also stated that the resident should seek legal counsel and that the agreement could be rescinded in writing within 30 days by certified mail. However, interviews with residents and representatives who had signed these agreements showed no evidence that staff clearly explained these provisions or confirmed that signers understood what they were agreeing to. One resident with multiple sclerosis, muscle spasms, contractures, anemia, and weakness was cognitively intact with a BIMS score of 14 and had electronically signed the arbitration agreement as his own representative. He reported understanding the concept of arbitration generally but did not remember signing the facility’s arbitration agreement and stated he was not clear on what he was signing at the time. He did not recall the admissions staff clearly explaining that he should seek legal counsel before signing or that he would be giving up certain legal rights, and he stated that he would not have signed had he understood this. Another resident with dysphagia, hemiplegia following cerebral infarction, a gastrostomy, type 2 diabetes, cognitive communication issues, generalized muscle weakness, and gout had an initial BIMS score of 0, indicating severely impaired cognition, and a later BIMS score of 15, indicating intact cognition. The arbitration agreement for this resident was signed by the resident and an emergency contact as representative. During a telephone interview, the emergency contact stated they did not remember signing anything that would prevent the resident or family from taking the facility to court, and that the arbitration process and agreement were not made clear before signing. A third resident with rib fracture, protein-calorie malnutrition, atrial fibrillation, systolic congestive heart failure, generalized muscle weakness, and cognitive communication deficit was documented as her own responsible party and had a BIMS score of 15, indicating intact cognition. The arbitration agreement in her record was electronically signed by an emergency contact as her representative. The resident stated she did not remember signing any legal papers like that, noted there were many papers to sign at admission, and reported that a family member present at admission would not have allowed her to sign such a document. A fourth resident with hemiplegia, clavicle fracture, hematuria, generalized muscle weakness, adjustment disorder, and cognitive communication deficit had a BIMS score of 14 and a power of attorney as representative. The arbitration agreement was electronically signed by the representative, who later stated she did not understand what she was signing, was unsure how arbitration works, and was more focused on the resident’s health at the time. She did not recall being advised to seek legal counsel or being clearly informed that signing meant giving up the right to pursue legal action in court. The Director of Admissions reported that arbitration agreements are included in the admission packet and that she waits for a BIMS score before reviewing them with residents or representatives. She stated that for residents with BIMS scores of 12 or higher, she meets with the resident and/or representative to review the admission packet and arbitration agreement, and for residents with lower BIMS scores she meets with the representative if they wish to sign. She described asking whether they had heard of binding arbitration and explaining that by signing they agree to use the facility’s arbitrator rather than their own legal counsel for unresolved grievances, disputes, or legal matters, and that signing is voluntary and not required for admission. She also stated she tells them they have 30 days to change their minds, but acknowledged that the process she described for rescinding—contacting her by phone or in person so she can notify the regional office—is not outlined in the document itself, which specifies rescission by written notice via certified mail. When asked how she determines understanding, she stated that she simply asks if they understand, and surveyor interviews found no evidence that staff explanations ensured residents or representatives truly understood the binding arbitration agreements they signed.
Failure to Ensure Neutral, Mutually Agreed Arbitration Terms in Admission Agreements
Penalty
Summary
Facility staff failed to ensure that binding arbitration agreements between the facility and residents or their representatives included language that a neutral arbitrator, agreed upon by both parties, would be selected and that the arbitration venue would be convenient to both parties. The facility’s most recent admission packet contained a Resident-Facility Binding Arbitration Agreement that required disputes related to services or health care to be resolved exclusively by binding arbitration and documented that by signing, parties waived their rights to have claims decided in court. However, the agreement did not contain any language stating that the arbitrator would be neutral and mutually agreed upon, nor that the location of arbitration would be convenient to both parties. For one resident with multiple sclerosis, muscle spasms, vitamin deficiencies, contracture, anemia, and weakness, the face sheet showed he was his own responsible party and an admission MDS documented intact cognition with a BIMS score of 14. A binding arbitration agreement was electronically signed by this resident and the Admissions Director. In a face-to-face interview, the resident stated he did not recall the Admissions staff explaining that a neutral arbitrator and a neutral location, selected by both parties, would be used if arbitration occurred. Another resident with dysphagia, hemiplegia and hemiparesis following cerebral infarction, a gastrostomy, type 2 diabetes mellitus, cognitive communication issues, generalized muscle weakness, and gout had an arbitration agreement signed by an emergency contact as the resident’s representative and the Admissions Director. The admission MDS showed a BIMS score of 0, while a later quarterly MDS showed a BIMS of 15. During a telephone interview, the emergency contact stated they did not remember admission staff explaining that they could select a neutral arbitrator and a neutral, convenient location for arbitration. A third resident with a left rib fracture, protein-calorie malnutrition, atrial fibrillation, systolic congestive heart failure, generalized muscle weakness, and a cognitive communication deficit was listed as her own responsible party, with multiple emergency contacts. The arbitration agreement was electronically signed by one emergency contact as the resident’s representative and by the Admissions Director, and the admission MDS showed intact cognition with a BIMS score of 15. In a face-to-face interview, this resident stated facility staff did not explain that both parties could choose a neutral arbitrator and a neutral location for arbitration. A fourth resident with hemiplegia affecting the right dominant side, a displaced fracture of the right clavicle, hematuria, generalized muscle weakness, adjustment disorder with mixed disturbance of emotions and conduct, and a cognitive communication deficit had a power of attorney as representative. The arbitration agreement was electronically signed by the representative and the Admissions Director, and the admission MDS showed a BIMS score of 14. In a telephone interview, the representative stated they did not recall anyone from Admissions explaining that a neutral arbitrator and neutral location would be selected by both parties. Interviews with residents, representatives, and emergency contacts who had signed arbitration agreements showed no evidence that staff explained these rights, and the Admissions Director acknowledged that the agreement lacked language regarding selection of the arbitrator and location for arbitration.
Failure to Manage Norovirus Outbreak, Perform Hand Hygiene, and Annually Review Infection Control Policies
Penalty
Summary
Facility staff failed to implement appropriate infection control measures during a cluster of residents with nausea and vomiting consistent with a Norovirus outbreak. Within a five‑day period, four residents on one floor and one resident on another floor developed vomiting, often with undigested food particles, and some required PRN Zofran or transfer to the ER for evaluation and treatment. These residents, including those with significant cognitive impairment and dependence for ADLs, remained in semi‑private rooms with roommates who were initially asymptomatic. The daily census showed that unoccupied rooms were available, yet there was no documented evidence that symptomatic residents were moved to private rooms or separated from unaffected roommates. One resident became ill after being allowed to cohort with a roommate who had exhibited vomiting the previous day. In an interview, the infection preventionist stated they believed it was an isolated incident and did not think affected residents needed to be moved. Facility staff also failed to perform required hand hygiene while handling meal trays and providing set‑up and feeding assistance to three residents. During a breakfast observation, a CNA delivered and set up trays for one resident, then for a second resident, and then for the second resident’s roommate, including raising bed heads, repositioning bedside tables, removing dome covers, unwrapping utensils and straws, opening milk cartons, cutting food, and providing direct feeding assistance, all without performing hand hygiene between residents or between contact with residents’ environments. The facility’s hand hygiene policy required hand hygiene before touching a resident, before preparing or handling food, after touching a resident, and after touching a resident’s environment, and specified ABHR as the preferred method unless hands were visibly soiled. When interviewed, the CNA stated she must have forgotten, and the unit manager and DON acknowledged the observations. In addition, the facility did not conduct an annual review of two infection control policies related to COVID‑19. The “COVID‑19 Resident Vaccination Policy” showed a revision date of June 1, 2022, and the “COVID‑19 PPE, source control for Healthcare personnel” policy showed a revision date of June 2023, with no evidence of annual review as required by the facility’s infection prevention and control program. During an interview, the infection preventionist acknowledged these findings and stated that they wait to receive updates from the regional office.
Failure to Maintain Kitchen Dishwashing and Drainage Equipment in Safe Operating Condition
Penalty
Summary
Facility staff failed to maintain kitchen equipment in safe operating condition, as observed during an initial kitchen survey. Surveyors noted that the automatic dishwasher’s pressure gauge was nonfunctional, and the backflow preventer valve located next to the pressure gauge on the automatic dishwashing machine was leaking water. Water was observed spraying out of the dishwashing machine while it was operating, and plastic bags had been placed on top of the machine in an attempt to stop the spray. In addition, the spray hose was stored on the garbage scrap board below the floor rim level, with no hook or hanger provided to keep it above the flood rim level when not in use. Surveyors also observed that a condensate water drainpipe from an air conditioning unit above the ceiling had been extended through a ceiling tile and was draining directly into the garbage disposer sink. These conditions were observed and acknowledged during a face-to-face interview with the Food Service Manager and the Maintenance Director at the time of the survey.
Failure to Maintain Effective Pest Control in Kitchen Dry Storage Area
Penalty
Summary
Facility staff failed to maintain an effective pest control program to ensure the facility was free of pests, as evidenced by surveyor observations in the kitchen dry storage room. During a follow-up kitchen survey on 03/10/2026 at approximately 12:50 PM, a dead cockroach was observed on the floor of the dry storage room. Review of pest control reports from the contracted pest management company dated 02/07/2026 and 02/28/2026 documented that no cockroach activity had been noted in the kitchen during those visits. In face-to-face interviews conducted at approximately 12:50 PM on 03/10/2026, the Food Service Manager and Maintenance Staff acknowledged the presence of the dead cockroach, and in a separate interview at approximately 1:10 PM, the Administrator stated that the professional pest exterminator services the facility biweekly and as needed. No residents were directly referenced in the report, and no resident conditions or medical histories were described in relation to this deficiency.
Failure to Develop Comprehensive Care Plan for Foley Catheter Use
Penalty
Summary
Facility staff failed to develop a comprehensive care plan with goals and interventions to address a resident’s use of an indwelling Foley catheter. The resident was admitted from a hospital on a stretcher with a Foley catheter draining yellow urine and had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, gastrostomy status, and aphasia. An admission note documented the presence of the Foley catheter, a subsequent MDS assessment coded the resident as having an indwelling catheter, and a physician’s order specified the Foley catheter was in place due to obstructive uropathy. During observation, the resident was seen in bed with a Foley catheter to bedside drainage. Review of the medical record showed no documented evidence that a comprehensive care plan with measurable goals and specific interventions was developed to address the resident’s Foley catheter use, and the DON confirmed that the last care plan meeting occurred shortly after admission and that staff had not created such a care plan for the catheter. This deficiency was identified for one of twelve sampled residents during the survey and was cross-referenced to 22B DCMR Sec. 3210.4.
Incorrect Morphine Route Transcription for NPO Hospice Resident
Penalty
Summary
Facility staff failed to ensure that a resident was free from a significant medication error when a morphine order was entered and maintained with an incorrect route of administration. The resident was admitted with multiple diagnoses including seizure disorder, adrenal insufficiency, bowel dysfunction, DM, intellectual delay, Ogilvie syndrome, gastrostomy status, dependence on supplemental oxygen, aspiration pneumonia, and was on hospice/comfort care. The resident had a malfunctioning G-tube and was ordered NPO with no GT use due to prior massive abdominal distention and stomach collapse. Despite this, a physician’s order for morphine sulfate concentrate was written and transcribed as an oral medication, even though the resident could not receive anything by mouth. On admission, the nurse assigned to the resident reviewed the hospital discharge medication list with the physician and then transcribed the approved orders into the electronic health record. The morphine sulfate order was entered as “by mouth” on the MAR, and this incorrect route was not corrected by the admitting nurse, the unit manager performing the 24-hour chart check, the dispensing pharmacist, the consultant pharmacist, or the Medical Director. The facility’s Medication Transcription policy required that all medication orders be transcribed accurately and match the prescriber’s order, and that medications from external sources be reviewed for accurate dosage and approved by the physician before administration. However, there was no documentation showing that any of the involved clinicians identified or corrected the oral route for morphine in light of the resident’s NPO status and non-functioning G-tube. The March MAR showed that the morphine sulfate oral solution was never administered to the resident during the stay, but the incorrect oral route remained on the MAR throughout. The NCC MERP definition of medication error, cited in the report, includes preventable events at any stage of the medication management process, including prescribing, transcribing, and dispensing, and notes that the potential for harm exists even if an error is caught before administration. During interview, the DON confirmed the admission and transcription process and could not provide any documentation from the dispensing pharmacy indicating the morphine order was incorrect. The LPN who completed the 24-hour chart check acknowledged that she did not consider the route for morphine during her review, stated that the medication could have been given by another route, and agreed that the situation was a near miss and an error.
Failure to Use Required PPE for Residents on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow the infection prevention and control policy and physician orders for residents on Enhanced Barrier Precautions (EBP). One resident with hemiplegia, hemiparesis following cerebral infarction, gastrostomy status, aphasia, a G-tube, Foley catheter, and wounds had a care plan and physician order specifying EBP, including the use of gown and gloves for high-contact resident care activities such as bathing. An EBP sign was posted at the room entrance instructing providers and staff to wear gloves and a gown for high-contact activities including dressing, bathing/showering, changing linens, providing hygiene, changing briefs or assisting with toileting, and device care or use for urinary catheters and feeding tubes. During observation, a CNA was seen bathing this resident while wearing a face mask and gloves but not a gown, despite acknowledging awareness that the resident was on EBP and stating she had simply forgotten to wear the gown. Another resident, admitted with bilateral above-knee amputations, COPD, gout, osteoarthritis, hypertension, BPH, urinary retention, dysphagia, and a Stage IV pressure ulcer present on admission, also had an EBP sign posted outside the room. The sign directed that everyone must clean their hands before entering and when leaving, and that providers and staff must wear gloves and a gown for high-contact resident care activities including dressing, bathing/showering, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. During observation, a CNA was providing a bed bath and changing the resident’s gown while wearing gloves but no gown. The CNA completed the care, disposed of the soapy water in the sink, removed gloves, performed hand hygiene, and handled the dirty linens, but did not use a gown at any point during the high-contact care, despite later stating that proper PPE for bathing a resident on EBP includes both a gown and gloves.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Facility staff failed to provide a clean, homelike environment for two residents. For Resident #132, the air conditioning/heating unit in their room was observed with thick layers of gray dust-like material, and the over-bed table was sticky, wet, and had dark-colored stains. The Director of Housekeeping and Laundry acknowledged these findings and stated that cleaning these areas is part of housekeeping duties. For Resident #113, the room was observed to have two large areas of chipping paint and a large hole on the right wall. The Director of Maintenance acknowledged these findings and mentioned that the maintenance staff had noted the issue during daily rounds but failed to enter it into the electronic system for further action.
Failure to Investigate Allegations of Abuse, Neglect, and Unusual Occurrences
Penalty
Summary
The facility's staff failed to thoroughly investigate multiple allegations of abuse, neglect, and unusual occurrences involving five residents. For Resident #228, the facility did not interview all staff members who worked during the shift when the alleged inappropriate touch by a CNA occurred. The investigation packet lacked statements from three out of five employees who were on duty, despite the Director of Nursing (DON) claiming that statements were obtained from all staff members on that shift. Additionally, the resident's cognitive function was moderately impaired, and the resident required extensive assistance for toileting and was frequently incontinent of urine and bowel, which further necessitated a thorough investigation. For Resident #230, the facility did not interview all staff members who worked during the shift when the resident alleged verbal abuse by a male staff member. The investigation packet only contained statements from three out of six employees who were on duty. The resident had a history of verbal behavioral symptoms directed towards others and rejection of care, which should have prompted a more comprehensive investigation. The DON acknowledged the missing statements but could not provide an explanation. The facility also failed to investigate Resident #229's fall incident, which resulted in the resident's death. The resident was found unresponsive on the floor, and there was no documented evidence of an investigation into the fall. Similarly, the facility did not investigate Resident #331's allegation of a verbal altercation with another resident, and the administration was not informed of the incident by the social worker. Lastly, the facility did not investigate an allegation of abuse and an unusual occurrence involving Resident #332, who had severe cognitive impairment. The medical record lacked evidence of investigations into these incidents, and the DON confirmed that no investigations were conducted.
Failure to Report Allegations of Abuse and Unusual Incidents
Penalty
Summary
The facility staff failed to report allegations of abuse and an unusual incident to the State Agency for two residents. For the first resident, there was an allegation of a verbal altercation with another resident, which was documented in the social work progress note. However, the facility did not conduct an investigation or report the incident to the State Agency. The Director of Nursing stated that the administration was not informed of the allegation by the social worker, which led to the social worker's termination. Additionally, a complaint was submitted to the State Agency regarding the resident's fall and subsequent lack of medical attention, but there was no documented evidence of an investigation by the facility into the verbal altercation or the fall incident. The resident had multiple diagnoses, including Cirrhosis of the Liver, Muscle Weakness, and Cognitive Communication Deficit, and was admitted to the facility on January 5, 2023. The complaint intake documented concerns about the facility's cleanliness, staff attentiveness, and safety environment, but the facility failed to address these issues adequately. The medical record lacked evidence of an investigation into the resident-to-resident altercation, and the administration was not informed of the incident by the social worker, leading to the social worker's termination. The Director of Nursing confirmed that the facility did not report the incident to the State Agency. For the second resident, there were multiple incidents that were not reported to the State Agency. The resident was transferred to the hospital due to a chronic UTI that advanced to E-coli, causing confusion and cognitive decline. The resident's daughter reported bruising and scratching observed at the emergency department and accused a CNA of hitting the resident. The facility did not investigate or report this allegation of abuse. Additionally, there was an incident where the resident's daughter was observed trying to administer supplements and other substances to the resident without consulting the clinical team. The facility staff documented the incident but did not investigate or report it to the State Agency. The resident had multiple diagnoses, including Diabetes Mellitus Type 2 with Diabetic Chronic Kidney Disease, Dysphagia, Oropharyngeal Phase, and Vascular Dementia, and was admitted to the facility on an unspecified date. The medical record lacked evidence of an investigation into the incident described in the Speech Therapy Treatment Encounter Note. The Director of Nursing confirmed that the facility did not report the incident to the State Agency. The medical record also lacked evidence of an investigation into the unusual occurrence documented in the nursing progress note. The Director of Nursing confirmed that the facility did not report this incident to the State Agency.
Failure to Document Corrective Actions and Investigate Abuse Allegations
Penalty
Summary
Facility staff failed to have documented evidence that they took corrective actions to protect and prevent further potential abuse of Resident #103 by Employee #13 after an allegation of physical abuse. Resident #103, who has schizophrenia and depressive disorder, reported that Employee #13 put his hands on his left shoulder. Although Employee #13 was suspended and received abuse training, there was no documented evidence that Employee #13 was removed from the position of Smoke Aide until six months later. During this period, Employee #13 continued to work in the same role, which was against the facility's policy to prevent retaliation or further abuse. The facility staff also failed to investigate Resident #331's report of a verbal altercation with another resident. Resident #331, who has cirrhosis of the liver, muscle weakness, and cognitive communication deficit, reported the altercation to a social worker. However, there was no documented evidence that the facility conducted an investigation into this allegation. The Director of Nursing stated that the administration was not informed of the allegation by the social worker, which contributed to the lack of investigation. Additionally, the facility staff failed to investigate an allegation of abuse and an unusual incident concerning Resident #332. Resident #332, who has multiple diagnoses including diabetes mellitus type 2 and vascular dementia, was reported to have been hit by a CNA and was observed with bruising and scratching. Furthermore, an unusual incident was documented where Resident #332's representative was found trying to administer unapproved supplements and medications. Both incidents lacked documented evidence of an investigation by the facility staff.
Failure to Provide Timely Bed-Hold Notices
Penalty
Summary
Facility staff failed to provide two residents or their representatives with bed-hold notices upon transfer to the hospital. Resident #87, who had intact cognition, was transferred to the hospital for evaluation and treatment of a worsening sacral stage 4 wound. The Notice of Discharge, Transfer, or Relocation Form was submitted a week after the transfer, which was acknowledged as an oversight by the social worker. The resident was readmitted to the facility without having received the required written notice specifying the duration of the bed-hold policy. Resident #278, who had severely impaired cognitive function, was transferred to the hospital for a CT scan and evaluation after a bump was observed on the left side of the head. The Notice of Discharge, Transfer, and Relocation Form was completed 15 days after the initial transfer and 10 days after the resident had already been readmitted to the facility. The social worker acknowledged the delay but could not provide a reason for it. Both instances demonstrate a failure to comply with the requirement to provide timely bed-hold notices to residents or their representatives upon hospital transfer.
Inaccurate MDS Coding for Falls and Surgical Wound
Penalty
Summary
Facility staff failed to accurately code the Quarterly Minimum Data Set (MDS) assessments for two residents, leading to deficiencies in the documentation of their medical conditions. Resident #379, who had a history of falls and multiple diagnoses including dementia and anxiety, was not accurately coded for a fall that occurred on 12/26/22. The resident's medical record showed two falls, one on 12/26/22 with no injury and another on 01/13/23 with a minor head injury. However, the Quarterly MDS assessment only documented one fall with a minor injury, missing the fall on 12/26/22. This discrepancy was acknowledged by the MDS Coordinator during an interview on 11/06/23, who stated that the resident's MDS assessment would be corrected to include the missed fall. Similarly, Resident #174's Admission MDS assessment was inaccurately coded, failing to reflect the resident's surgical wound. The resident, admitted with diagnoses including extradural and subdural abscess and osteomyelitis of the vertebra, had undergone a lumbar laminectomy and had a wound vac in place. Despite this, the Admission MDS assessment did not capture the surgical wound on the resident's right lower back. This error was also acknowledged by the MDS Coordinator during an interview on 11/06/23, who stated that the MDS would need to be modified to include the surgical wound. These inaccuracies in the MDS assessments highlight a failure in the facility's documentation processes, which are crucial for ensuring accurate and comprehensive care plans for residents. The deficiencies were identified through record reviews and staff interviews, revealing gaps in the coding of significant medical events and conditions for the residents involved.
Failure to Implement Care Plan for Use of Palm Guards
Penalty
Summary
Facility staff failed to implement a resident's care plan for the use of carrot palm guards to prevent skin integrity impairment and further immobility/contractures. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, had a physician's order for the use of carrot palm guards to be applied for specific periods. However, during multiple observations, the resident was found without the palm guards, and the guards were not present in the resident's room. The resident's refusal to keep the palm guards on was not documented in the care plan, and the physician was not informed of the resident's non-compliance. During an interview, the Restorative Nurse Manager acknowledged that the resident often removed the palm guards and that this issue had not been communicated to the physician or included in the resident's care plan. The failure to implement the care plan and address the resident's refusal to wear the palm guards resulted in a deficiency in the resident's care, as the necessary interventions to prevent further contractures and skin integrity issues were not consistently applied.
Failure to Ensure Appropriate Treatment for Limited Range of Motion
Penalty
Summary
Facility staff failed to ensure that a resident with a limited range of motion received the appropriate treatment and services to increase the resident's range of motion or prevent further decrease. The resident, who had diagnoses including muscle wasting, atrophy, and contractures, was observed multiple times without the prescribed palm guards. Staff interviews revealed that the resident frequently removed the palm guards, but this behavior was not communicated to the physician for alternative treatment options. The medical record indicated that the resident was dependent on staff for all activities of daily living and had severely impaired cognition. Observations showed that the resident's hands were contracted, and the palm guards were either not applied or removed by the resident. Despite this, the Splint Monitoring Form inaccurately documented that the splints were applied and removed as scheduled. Staff admitted to knowing about the resident's behavior but failed to document it or inform the physician. During an attempt to reapply the palm guards, the resident expressed pain, indicating a further decline in range of motion. The facility staff's failure to provide appropriate treatment and communicate the resident's refusal to wear the palm guards to the physician led to the deficiency.
Failure to Supervise Resident During Toileting
Penalty
Summary
The facility staff failed to adequately supervise Resident #331 while toileting, as required by the resident's Minimum Data Set (MDS) assessment, which indicated the need for supervision and a one-person staff assist. Despite this requirement, the resident experienced two falls while attempting to use the bathroom independently. On one occasion, the resident fell while trying to go to the bathroom alone, and on another occasion, the resident fell after being left unattended on the commode. Both incidents were documented in the nursing progress notes and post-fall huddles, which recommended re-educating the resident to use the call light for assistance. The medical record lacked documented evidence that the facility staff provided the necessary supervision while toileting Resident #331. The Director of Nursing acknowledged that supervision with toileting means that staff should be present in the bathroom with the resident. The resident's medical history included cirrhosis of the liver, muscle weakness, and cognitive communication deficit, and the resident had a Brief Interview for Mental Status (BIMS) score indicating intact cognition. Despite these needs and the documented requirement for supervision, the facility failed to ensure the resident's safety, leading to the reported falls.
Failure to Follow Narcotic Reconciliation Procedures
Penalty
Summary
Facility staff failed to ensure that the established procedures for the accurate reconciliation of narcotics were followed. During an observation of the 3rd Floor narcotic book, it was noted that there was no signature in the section 'Balance verified by nurse coming on duty' for the 7:00 AM - 3:00 PM shift. This failure was evidenced by the lack of sign-off that the narcotic count was correct with the off-going nurse. During a face-to-face interview, an LPN stated that her shift started at 7:00 AM, and she had to run to the bathroom during the narcotic count, which led to her forgetting to sign off.
Lack of Physician Review Documentation for Pharmacy Regimen Review
Penalty
Summary
The facility staff failed to show documented evidence in the medical record that the physician reviewed the pharmacy regimen review for a resident with multiple diagnoses, including Dementia, Paranoid Schizophrenia, and Gastrostomy Status. The resident was admitted to the facility and had a BIMS summary score indicating intact cognition and was receiving antipsychotic medication. Pharmacy medication regimen reviews were conducted on several dates, but the physician's responses to these reviews were not present in the resident's medical record. During a face-to-face interview, a Quality Assurance employee acknowledged that the facility was in the process of transitioning to 100% electronic health records and that the physician's responses were kept in a binder in an office. This lack of documentation in the medical record constitutes a deficiency as it fails to comply with the facility's policy requiring that copies of drug/medication regimen review reports, including physician responses, be maintained as part of the permanent medical record.
Failure to Properly Store and Label Insulin
Penalty
Summary
Facility staff failed to store and label biologicals in accordance with currently accepted professional practices. During an observation of the 4th floor medication storage room, an opened Lantus vial was found without an open or expire date. A Licensed Practical Nurse (LPN) acknowledged the finding and discarded the vial. Additionally, during an observation of the 2nd floor medication cart, one Novolog pen was found without a resident label, and another Novolog pen was not labeled with the date it was opened or the expire date. The LPN acknowledged these findings and stated that the Novolog pens would be discarded.
Dishwasher Temperature Deficiency
Penalty
Summary
Facility staff failed to ensure that the dishwasher reached the required temperature to clean dishes and utensils under sanitary conditions. During an observation in the facility kitchen, it was noted that the high temperature dishwasher, during the wash cycle, reached a high of 130 degrees Fahrenheit. In a second observation, the wash cycle temperature reached a high of 132 degrees Fahrenheit. During a face-to-face interview at the time of both observations, the Food Service Director acknowledged the findings and stated that the Maintenance Director would be notified to address the issue.
Inaccurate Documentation in Resident Medical Records
Penalty
Summary
The facility staff failed to ensure accurate documentation in the medical records of three residents. For Resident #229, the Post Fall Huddle inaccurately documented the fall as witnessed, and the Facility Reported Incident did not include that the resident expired in the facility and was discharged to a funeral home. The resident was found unresponsive on the floor, CPR was initiated, and EMS pronounced the resident dead. However, the incident report sent to the State Survey Agency omitted the resident's death and subsequent discharge to the funeral home. For Resident #132, the facility staff failed to accurately document the resident's refusal of care in the Treatment Administration Record (TAR). Despite the resident's refusal to get out of bed and wear a back brace, the TAR inaccurately indicated that the care was administered. The resident, who had intact cognition, refused to get out of bed multiple times, but the staff documented that the care was provided as per the physician's order. For Resident #128, the facility staff failed to accurately document the presence of open areas on the resident's weekly skin assessments. Despite having multiple pressure ulcers and other skin issues, the weekly skin assessments inaccurately documented the condition of the resident's skin as having no new skin alterations. The wound nurse and an LPN acknowledged that the weekly skin assessments were inaccurate and that they thought they were only to document new wounds.
Failure to Update Hospice Care Plan
Penalty
Summary
The facility staff failed to ensure that a resident had a current written hospice care plan that included both the most recent hospice plan of care and a description of the care and services furnished by the long-term care facility. The resident, who had multiple diagnoses including Parkinson's Disease and dementia, was admitted to the facility and was receiving hospice services. However, the nursing home care plans for the resident had not been updated since June 29, 2023, and did not include or specify the care and services that were to be provided by the hospice agency. The hospice plan of care for the resident, dated June 23, 2022, included various interventions and safety measures but had not been updated to reflect the most recent care needs. Additionally, the hospice plan of care did not specifically identify which hospice provider was responsible for performing the respective functions. The resident's medical record lacked documented evidence that facility staff updated the comprehensive person-centered care plan to include the hospice agency's care plan for the resident. During interviews, a hospice nurse stated that the hospice plan of care had been updated since June 29, 2023, but was not aware that the facility did not have a copy of the most recent hospice plan of care. A registered nurse acknowledged that the resident's comprehensive care plan had not been updated and did not include the hospice plan of care. This failure to maintain and update the care plans led to the deficiency identified by the surveyors.
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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