Knollwood Hsc
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 6200 Oregon Ave Nw, Washington, District Of Columbia 20015
- CMS Provider Number
- 095026
- Inspections on file
- 14
- Latest survey
- May 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Knollwood Hsc during CMS and state inspections, most recent first.
A resident with multiple risk factors and on high fall risk medications experienced three unwitnessed falls in one month, including one with injury, due to inadequate monitoring and lack of documented rounding by staff. Despite facility policy requiring regular documented rounds and medication review, staff did not maintain written logs or adjust medications after the initial fall, resulting in continued risk and harm.
Facility staff did not follow policy requiring removal of a CNA from resident care during an abuse investigation. A resident with multiple medical and psychiatric conditions reported that a CNA was verbally rough and handled her belongings harshly. Despite the ongoing investigation, the CNA continued to work and provide care to the resident, contrary to facility policy.
A resident with multiple chronic conditions was discharged to assisted living without a required physician discharge summary, which should have included a recapitulation of the stay, final status, and medication reconciliation. Nursing and social work notes documented the discharge process, but the physician's summary was missing from the medical record.
Facility staff did not update care plan interventions for a resident with a history of aggressive behaviors after two separate incidents of aggression toward another resident. Despite documented behavioral issues and psychiatric involvement, the care plan lacked new approaches to prevent further inappropriate contact, and the DON acknowledged that updates should have been made after each event.
A resident with multiple diagnoses was incorrectly administered Lorazepam due to a transcription error by an RN, who failed to mark the medication as PRN in the electronic record. This resulted in the resident receiving the medication routinely without signs of agitation or restlessness.
Failure to Monitor and Document Supervision for High Fall Risk Resident
Penalty
Summary
Facility staff failed to adequately monitor and supervise a resident identified as high fall risk, resulting in three unwitnessed falls within a single month. The resident had multiple diagnoses, including osteoarthritis, psychotic disorder, syncope, muscle weakness, and a history of falls, and was prescribed several high fall risk medications such as Ambien, Eliquis, Depakote, and Clonazepam. Despite these risk factors, there was no documented evidence that staff maintained a written log of regular monitoring or rounding as required by facility policy, nor were medication regimens reviewed or adjusted after the initial fall. The facility's policies required a fall risk assessment on admission and at least quarterly, with additional assessments after any fall, and mandated regular rounding with documentation of date, time, staff, and observations. However, staff interviews revealed that while CNAs and nurses claimed to round on the resident every one to two hours, there was no documentation in the electronic health record or written logs to verify these rounds. The lack of documentation persisted across all three falls, and staff acknowledged that there was no system in place for CNAs to record their rounds, contrary to policy requirements. After each fall, assessments indicated the resident remained at high risk, but no changes were made to the medication regimen until after the second fall. The third fall resulted in a significant injury, with the resident sustaining fractures to the right ankle. Throughout these incidents, the facility did not provide evidence of consistent monitoring or timely response as outlined in their own procedures, nor did they document interdisciplinary team actions to address the resident's ongoing fall risk.
Failure to Remove Alleged Abuser from Resident Care During Abuse Investigation
Penalty
Summary
Facility staff failed to implement their written policies and procedures for investigating incidents of abuse for one of eight sampled residents. According to the facility's policy, when an abuse allegation is made, the alleged abuser must be removed from resident care pending the investigation. However, documentation and staff interviews revealed that the certified nurse assistant (CNA) accused of being verbally rough with a resident continued to work and provide care to the resident during the investigation period. The incident involved a resident with multiple diagnoses, including chronic diastolic congestive heart failure, schizophrenia, unspecified dementia, and major depressive disorder, who was assessed as having intact cognition and requiring extensive assistance for daily activities. The resident reported that a CNA was verbally rough and handled her belongings in a manner she found upsetting. The facility's investigation included statements from the CNA, the former Director of Nursing (DON), and interviews with other residents, but the CNA remained on duty and assigned to the resident throughout the investigation. A review of assignment sheets and timesheets confirmed that the CNA continued to work on the unit and care for the resident during the period in which the abuse allegation was being investigated. Both the current DON and the CNA acknowledged in interviews that, according to facility policy, the staff member should have been removed from resident care during the investigation, but this did not occur.
Missing Physician Discharge Summary for Discharged Resident
Penalty
Summary
Facility staff failed to provide a physician discharge summary for one of eight sampled residents who was discharged home. The resident had multiple diagnoses, including chronic diastolic congestive heart failure, schizophrenia, unspecified dementia, major depressive disorder, and a history of tobacco use. Documentation in the medical record included nursing and social work progress notes detailing the resident's admission, ongoing care, and discharge process. The notes indicated that the resident was alert, verbally responsive, and discharged in stable condition to an assisted living apartment, with personal belongings and care instructions transferred accordingly. Despite these records, there was no documented evidence of a physician discharge summary that included a recapitulation of the resident's stay, a final summary of the resident's status, or a reconciliation of all pre-discharge medications. The absence of this required documentation was confirmed during a face-to-face interview with the Director of Nursing, who acknowledged the deficiency in the resident's medical record.
Failure to Update Care Plan Interventions Following Resident-to-Resident Aggression
Penalty
Summary
Facility staff failed to update care plan interventions for a resident with a known history of aggressive behaviors, resulting in two separate staff-witnessed incidents where this resident acted aggressively toward another resident. The first incident involved one resident hitting another on the shoulder while being escorted to the hair salon. The affected resident displayed pain cues but denied pain or discomfort upon assessment, and no physical injuries were observed. The care plan for the resident who was hit was updated to include monitoring for injury and providing emotional support, but the care plan for the resident who exhibited aggression was not revised with new interventions to prevent further incidents. The resident with aggressive behaviors had a documented history of Alzheimer's Disease, depression, and agitated dementia, and was already under psychiatric care for these behaviors prior to the incidents. Medical records and psychiatric notes indicated ongoing issues with aggression, particularly after lunch, and described the resident as having a quick temper and being physically aggressive at times. Despite these documented behaviors and the occurrence of the first incident, there was no evidence that the care plan was updated with new approaches or interventions to address the risk of further aggression toward the other resident. A second incident occurred in which the same resident was reported to have slapped the other resident on the face. Staff investigation found that a threat was made, but no physical contact was confirmed by witnesses. The care plan for the resident who was threatened was updated to include monitoring and a psych consult, but again, the care plan for the resident with aggressive behaviors was not revised with new interventions after this second event. The Director of Nursing acknowledged during interview that the care plan should have been updated with new approaches after each incident, but this was not done.
Medication Transcription Error Leads to Incorrect Lorazepam Administration
Penalty
Summary
Facility staff failed to accurately transcribe a physician's order for Lorazepam, leading to a significant medication error for a resident. The resident, who was admitted with multiple diagnoses including cerebral infarction and hemiplegia, was prescribed Lorazepam 0.5mg every 4 hours as needed for anxiety and restlessness. However, the order was incorrectly entered into the electronic Medication Administration Record as a routine medication instead of PRN (as needed), resulting in the resident receiving the medication five times in one day without documented evidence of agitation or restlessness. The error was identified when a Facility Reported Incident was submitted, revealing that the nurse responsible for entering the order did not check the PRN box, causing the medication to appear as a routine order. The Director of Nursing confirmed that the transcription error was made by an RN, who admitted to the mistake during an interview, acknowledging the failure to indicate the medication as PRN. This transcription error led to the resident receiving unnecessary doses of Lorazepam, despite being on hospice services for comfort care.
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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