Serenity Rehabilitation And Health Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 1380 Southern Ave Se, Washington, District Of Columbia 20032
- CMS Provider Number
- 095015
- Inspections on file
- 18
- Latest survey
- January 16, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Serenity Rehabilitation And Health Center Llc during CMS and state inspections, most recent first.
Facility staff failed to accurately code a resident’s Quarterly MDS for a sacral deep tissue injury (DTI). Nursing notes and wound assessments documented that an open area on the sacrum was first observed after admission, later assessed as a full-thickness pressure ulcer with maroon discoloration and identified as an in-house–acquired DTI. Despite this, the MDS was completed indicating one unstageable pressure injury present on admission rather than facility acquired, and the MDS coordinator later acknowledged that the sacral wound had been miscoded.
A diabetic resident with intact cognition and multiple comorbidities was admitted with orders and care plan interventions requiring daily foot inspections, referral to podiatry or a foot care nurse, and nail care. Over several weeks, repeated skin and wound notes recommended routine in‑house podiatry evaluation for thickened nails, and a podiatrist was present in the facility on multiple occasions, yet the resident was never seen by podiatry. Weekly nurse skin assessments documented no skin impairment and continued the plan of care without addressing the toenails. On observation, the surveyor, CNA, LPN, DON, and unit manager all noted overgrown, thickened, yellow toenails on both feet, with several nails curved and digging into the skin, and staff confirmed the resident had not received podiatry services, while the administrator cited pending Medicaid coverage despite acknowledging the facility could have covered the cost.
Surveyors observed that staff did not consistently store medications in the correct resident compartments or on the appropriate medication carts, resulting in multiple instances where medications for one resident were found in another's storage area. These errors were acknowledged by staff and involved residents with various medical conditions and cognitive impairments. The facility's policy requires orderly and secure medication storage, but this was not followed, leading to medication discrepancies.
Staff failed to maintain sanitary food service by using wet dome covers on meal trays, did not follow infection control protocols during medication administration, and allowed a resident with behavioral symptoms to handle and dispose of soiled incontinence products in common areas while wearing gloves and double masks. These actions and inactions led to multiple breaks in infection control and sanitary practices.
A resident with paraplegia and intact cognition was not treated with dignity when staff entered her room without knocking or addressing her, despite a posted sign requesting this courtesy. The resident reported that staff often enter without speaking and do not use the privacy curtain during care, which was confirmed by observation and interviews.
A resident with multiple medical conditions and intact cognition did not receive required quarterly statements of her personal funds account for four consecutive quarters. Staff acknowledged the oversight, which was confirmed through record review and resident interview, in violation of facility policy requiring regular financial statements.
Facility staff did not adequately protect a resident's personal property, resulting in missing and unlabeled clothing items. The resident, who had severe cognitive impairment, was found to have discrepancies between the inventory sheet and actual belongings, and staff could not provide documentation of recent inventory checks.
Facility staff did not promptly report a resident's unexplained forehead swelling to the Administrator or State Agency, despite the resident's severe cognitive impairment and inability to explain the injury. The injury was only reported after the family raised concerns about possible abuse and additional bruising, and staff later acknowledged the delay in recognizing and reporting the incident as required.
Facility staff did not conduct a complete investigation into a resident's acute finger fracture of unknown origin. The resident, who was severely cognitively impaired and fully dependent on staff, was found with a swollen finger that was later diagnosed as fractured. The facility's investigation did not include statements from all relevant staff, as required by policy, and this was acknowledged by the DON.
Facility staff did not provide written notification of the bed hold policy, remaining bed hold days, or reserve bed payment to the representatives of two residents who were transferred to the hospital. In both cases, staff verbally notified the representatives of the transfers but failed to document or provide the required written information regarding bed hold procedures.
Facility staff failed to accurately code MDS assessments for three residents, resulting in incorrect documentation of opioid, antibiotic, antiplatelet, and diuretic medication use. In each case, the MDS did not reflect the actual medications administered or prescribed, as confirmed by care plans, physician orders, and medication administration records.
A resident with a diagnosis of Schizophrenia and prescribed antipsychotic medication was not referred for a required PASRR Level II evaluation when their stay was extended to LTC. Despite documentation of the mental disorder and ongoing treatment, staff did not complete the referral, citing time constraints and miscommunication regarding responsibility.
A resident with bilateral hearing loss and dementia did not receive functioning hearing aids as required by their care plan. Despite a physician's order for audiology evaluation and family efforts to provide assistive devices, staff were unaware of the resident's hearing aids or relied on ineffective alternatives, resulting in unmet communication needs.
Staff did not update the care plan for a resident with dementia and behavioral health issues who repeatedly wore gloves and double masks throughout the facility, despite ongoing staff redirection and continued observations of this behavior. The care plan interventions remained unchanged and did not address the resident's current actions, as confirmed by staff interviews and record review.
A resident with bilateral hearing loss and multiple comorbidities did not receive necessary assistance from staff to obtain or use functional hearing aids, despite care plan requirements and physician orders. Staff were unaware of the resident's hearing aid status, and the resident relied on ineffective alternative devices provided by family, resulting in diminished ability to communicate and perform daily activities.
A resident with hemiplegia, hemiparesis, and muscle weakness did not receive restorative nursing services to maintain or improve range of motion after discharge from OT, due to delays in order entry and lack of inclusion in the restorative program documentation. This resulted in a gap of 13 days without the required interventions.
A resident with a history of elopement and cognitive impairment was able to leave the facility unsupervised after staff failed to provide adequate monitoring, did not follow established elopement protocols, and left doors unsecured following a fire drill. Delays in recognizing the resident's absence and notifying administration contributed to the deficiency.
A resident with an indwelling Foley catheter and severe cognitive impairment was found with the catheter connection tube and drainage bag on the floor, contrary to care plan interventions designed to prevent urinary tract infections. Staff did not follow established protocols for catheter care, as confirmed by a unit manager during observation.
A nurse failed to follow proper insulin administration protocols for a resident with diabetes by administering insulin at the wrong time, using a syringe to withdraw insulin from a pen against manufacturer instructions, and not consulting the physician as required. The nurse also neglected infection control practices by not removing gloves or performing hand hygiene after the procedure, and did not keep the medication cart visible during administration.
Facility staff did not ensure that pharmacist recommendations from monthly drug regimen reviews and the corresponding physician responses were documented in the medical records for two residents with complex medical and psychiatric conditions. In both cases, required documentation was either missing from the electronic health record or not provided, despite staff interviews confirming the process was not consistently followed.
A registered nurse administered insulin to a resident with diabetes using a syringe to withdraw medication from a prefilled pen, contrary to manufacturer instructions and physician orders, and did so several hours before the scheduled time. The nurse did not consult a physician before making these changes and also failed to follow proper infection control procedures. The resident did not experience any harm.
A resident with multiple medical conditions, including diabetes and malnutrition, was not provided with a diet that met daily nutritional and special dietary needs, particularly regarding preferences for fresh fruits and vegetables. Despite care plan interventions and the availability of fresh produce, the resident did not receive requested food items or snacks, and staff interviews confirmed the failure to honor dietary preferences.
Inaccurate MDS Coding of Facility-Acquired Sacral DTI
Penalty
Summary
Facility staff failed to ensure an accurate assessment for one resident by incorrectly coding a facility-acquired pressure injury on the Quarterly MDS. The resident was admitted with multiple diagnoses including Type 2 diabetes mellitus, Alzheimer's disease, dementia, muscle weakness, and major depressive disorder. On 10/29/25, nursing staff identified an open area on the resident's sacrum during routine ADL/incontinent care, and the NP, wound team, and dietitian were notified. On 10/30/25, a comprehensive skin and wound assessment documented a sacral pressure ulcer/injury with full-thickness tissue loss and a central area of marooning, and the wound team determined it would be followed as a deep tissue injury (DTI). On 11/11/25, a wound/pressure ulcer note documented a sacral DTI pressure ulcer/injury that was specifically identified as in-house acquired. Despite this documentation, the Quarterly MDS assessment coded the resident as having one unstageable pressure injury that was present upon admission, rather than facility acquired. During an interview, the MDS coordinator reviewed the MDS, acknowledged the discrepancy, and stated that the sacral wound had been miscoded as present on admission instead of correctly coded as not present on admission.
Failure to Obtain Podiatry Care and Provide Foot Care for Diabetic Resident
Penalty
Summary
Facility staff failed to provide necessary podiatry consultation, treatment, and foot care for a diabetic resident over a three‑month period following admission. The resident was admitted with Type 2 Diabetes Mellitus, hyperlipidemia, cerebral infarction, and schizophrenia, and had physician orders for PRN podiatry consults as well as weekly skin assessments and heel offloading. Multiple skin and wound notes dated over several weeks (10/14, 10/21, 10/28, 11/07, and 11/14) repeatedly documented recommendations for routine in‑house podiatry evaluation for nail trimming and management of thickened nails. The resident’s care plan directed staff to inspect feet daily, refer to podiatry or a foot care nurse for monitoring and nail cutting, and to check nail length and trim and clean nails on bath days and as necessary. Despite these orders and care plan interventions, the resident was not seen by a podiatrist during the three months since admission, even though a podiatrist was documented as being in the facility on multiple occasions. Quarterly MDS data showed the resident had intact cognition and required supervision or touching assistance for bathing, lower body dressing, and footwear, indicating dependence on staff for foot care. Weekly skin assessments by licensed nurses in late December and early January documented no skin impairment and continuation of the plan of care, without addressing the ongoing need for podiatry services or the condition of the resident’s toenails. On observation, the surveyor noted that the resident’s toenails on both feet were overgrown, thickened, yellow, and in several toes curved downward and digging into the skin on the bottoms of the feet. The assigned CNA and LPN confirmed these findings when called to the room, and the LPN stated she had noticed that the toenails were long and that the resident needed to see podiatry. The DON and unit manager also observed the condition of the resident’s feet and confirmed that the resident had not been seen by a podiatrist since admission, although he was on the list to be seen. The administrator later stated that the resident’s Medicaid application was pending and that he did not yet have insurance coverage for podiatry, but acknowledged that exceptions could be made and the facility could cover the cost, which had not occurred during the three‑month period in question.
Failure to Properly Store Medications in Designated Resident Compartments
Penalty
Summary
Facility staff failed to properly store medications in accordance with professional standards and facility policy, as evidenced by multiple instances where medications were found in the wrong resident's individual compartment or on the incorrect medication cart. During observations, surveyors identified that medications prescribed for specific residents were stored in compartments assigned to other residents, and in one case, several blister packs for a resident were found on the wrong medication cart entirely. These errors were acknowledged by the staff members involved, who admitted to mistakenly placing the medications in the wrong locations. The residents affected had a range of medical conditions, including end stage renal disease, dementia, diabetes, cardiovascular disease, and cancer, with varying levels of cognitive impairment as documented by their Brief Interview for Mental Status (BIMS) scores. For example, one resident with end stage renal disease and moderate cognitive impairment had their acetaminophen stored in another resident's compartment, while another resident with severe cognitive impairment and hypothyroidism had their levothyroxine stored in the wrong compartment. Similar issues were observed for residents with dementia, coronary artery disease, and other complex medical needs, where their prescribed medications were not stored in their designated compartments. The facility's own 'Medication Storage' policy requires that all drugs and biologicals be stored in a safe, secure, and orderly manner, with nursing staff responsible for maintaining medication storage areas. The policy also mandates that any discrepancies with medications be reported to a supervisor immediately. Despite these requirements, the observed failures in medication storage demonstrate that staff did not consistently follow established protocols, resulting in medications being accessible in the wrong locations and potentially compromising the safe administration of drugs to residents.
Multiple Breaks in Infection Control and Sanitary Food Service
Penalty
Summary
Facility staff failed to maintain sanitary conditions during food distribution and service. During an observation in dietary services, staff were seen using wet dome covers on the tray line to help maintain hot food temperatures in serving plates. These dome covers were not allowed to air dry before use, exposing food to moisture and potential contamination. The dietary employee acknowledged this practice during an interview. Infection control standards and practices were not followed by staff, as evidenced by a registered nurse who was observed walking in the hallway wearing gloves and carrying an insulin syringe into a resident's room. After administering the insulin injection, the nurse exited the room still wearing the same gloves and holding the used, exposed syringe. The nurse then walked down the hall, discarded the syringe in the sharps container, and proceeded to touch the computer and medication cart without removing gloves or performing hand hygiene. The nurse acknowledged the failure to follow infection control protocols when questioned. There were also breaks in infection control related to the disposal of soiled incontinent pads and briefs. A resident with a history of behavioral symptoms and moderately impaired cognition was observed wearing gloves and double masks, carrying soiled incontinence pads and briefs, and disposing of them in a common area trash can. Staff interviews revealed that the resident often took out trash from his room due to dissatisfaction with staff response times and the practice of placing his roommate's soiled items in his trash can. Staff also acknowledged that both the resident's and the assigned CNA's behaviors could compromise infection control, and that interventions to address these behaviors had not been adequately updated.
Failure to Honor Resident Dignity and Privacy
Penalty
Summary
Facility staff failed to honor a resident's right to dignity and respect by entering the resident's room without knocking or addressing the resident, despite a clearly posted sign requesting staff to knock before entering. During an observation, a registered nurse opened the closed door to the resident's room, entered without knocking, and did not communicate with the resident before proceeding to adjust the window treatments for the resident's roommate. The nurse left the door open and did not acknowledge the resident upon entry. The resident, who has a history of paraplegia, neuromuscular dysfunction of the bladder, and mental health diagnoses including schizophrenia and bipolar disorder, was assessed as having intact cognition. The resident reported that staff frequently enter the room without speaking to her and do not use the privacy curtain when providing care. These actions were observed and confirmed during staff and resident interviews, demonstrating a failure to treat the resident with dignity and respect, and to recognize her individuality.
Failure to Provide Quarterly Personal Funds Statements to Resident
Penalty
Summary
Facility staff failed to provide a resident with quarterly statements of her personal funds account as required by facility policy and federal regulations. The resident, who was admitted with multiple diagnoses including cerebrovascular accident, anxiety, bilateral hip arthritis, and morbid obesity, was found to be cognitively intact based on a BIMS score of 14. During an interview, the resident stated she had not been receiving statement balances for her account and was unaware that she should be receiving regular quarterly statements. A review of the resident's fund statement confirmed that she did not receive quarterly statements for four consecutive quarters. Staff acknowledged the oversight, stating that while account balances are provided on withdrawal receipts and quarterly statements are typically given and signed for, the resident had not received her copies for the past quarters. The facility's policy requires that individual accounting records be made available to residents through quarterly statements, which must include specific financial details.
Failure to Safeguard Resident's Personal Property
Penalty
Summary
Facility staff failed to exercise reasonable care in protecting a resident's personal property from loss. The resident, who had multiple diagnoses including malignant neoplasm of laryngeal cartilage and benign prostatic hyperplasia with lower urinary tract symptoms, was documented as having severely impaired cognitive skills for decision-making. The resident's sister, who is the responsible party, reported that the resident's clothes frequently went missing despite being labeled, and expressed uncertainty about whether new items brought in were being added to the inventory sheet. During an observation of the resident's closet and drawers, multiple clothing items listed on the inventory sheet were missing, and several items found were neither labeled with the resident's name nor listed on the inventory sheet. The unit manager stated that inventory checks should occur during quarterly care plan meetings, but was unable to provide documentation that the resident's property had been inventoried during the last meeting. This demonstrates a failure to maintain accurate and up-to-date records of the resident's personal belongings, resulting in the loss of property.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
Facility staff failed to timely report an injury of unknown origin for a resident with multiple diagnoses, including severe cognitive impairment and physical health issues. The resident was found with swelling on the forehead, and staff were unable to determine the cause of the injury, as the resident could not communicate what had happened. Documentation showed that the swelling was noted during routine assessments, and the nurse practitioner and family were notified. However, the injury was not reported to the Administrator or the State Agency within the required timeframe. The delay in reporting was acknowledged by both the unit manager and the assistant director of nursing, who confirmed that the swelling should have been identified as an injury of unknown origin and reported accordingly. The incident only came to the attention of the State Agency after the resident's family raised concerns about possible abuse and additional bruising observed at the hospital. The facility's failure to recognize and report the injury in a timely manner constituted a deficiency in following required protocols for suspected abuse, neglect, or injury of unknown origin.
Failure to Conduct Thorough Investigation of Resident Injury
Penalty
Summary
Facility staff failed to conduct a thorough investigation into an injury of unknown origin involving a resident who was readmitted with multiple diagnoses, including surgical aftercare and adult failure to thrive. The resident was noted to have severe cognitive impairment, was totally dependent on staff for all activities of daily living, and had no prior functional impairment in the upper extremities. On one occasion, staff observed swelling in the resident's right index finger, which led to an x-ray and subsequent diagnosis of an acute fracture. The incident was reported to the state agency, and an investigation was initiated by the facility administrator. Upon review of the facility's investigation documents, it was found that staff did not obtain statements from all appropriate employees as required by the facility's policy on reporting and investigating abuse, neglect, exploitation, or injuries of unknown origin. The Director of Nursing acknowledged that not all staff statements were collected during the investigation, resulting in a failure to meet the facility's own standards for a thorough investigation.
Failure to Provide Written Bed Hold Notification During Hospital Transfers
Penalty
Summary
Facility staff failed to provide written notification to residents or their representatives regarding the facility's bed hold policy, remaining bed hold days, and reserve bed payment when two residents were transferred to the hospital. In both cases, the residents had representatives listed on their face sheets. For one resident with end stage renal disease, diabetes, bilateral above the knee amputation, and heart failure, staff documented the transfer to the hospital following a fall and head injury, but could not provide evidence of written notification about the bed hold policy to the resident's representative. Interviews with staff revealed that while verbal notification of the transfer was given, the responsibility for bed hold information was unclear and no written documentation was available. Similarly, for another resident with dementia, aphasia, psychotic disorder, and cerebrovascular accident with hemiplegia, staff documented the transfer to the hospital for respiratory distress and notified the emergency contact by phone about the change in condition. However, there was no documented evidence that written notification regarding the facility's bed hold policy, remaining bed hold days, or reserve bed payment was provided to the resident's representative. Staff interviews confirmed that the process for providing this information was not followed, and no written notification could be produced.
Inaccurate MDS Coding for Medication Administration
Penalty
Summary
Facility staff failed to accurately code Minimum Data Set (MDS) assessments for three residents, resulting in incomplete and incorrect documentation of their medication regimens. For one resident with diagnoses including pain, diabetes, bipolar disorder, and edema, the MDS assessment did not reflect the administration of opioid medications, despite ongoing orders and documentation of oxycodone and tramadol being given as prescribed. The resident's care plan and medication administration record confirmed regular receipt of these medications during the assessment period, but the MDS failed to indicate opioid use. Another resident, admitted with conditions such as cervical disc stenosis, lumbar stenosis, and benign prostatic hyperplasia, was prescribed and administered ciprofloxacin for a urinary condition. However, the admission MDS assessment did not indicate that the resident was receiving antibiotic therapy, even though the medication administration record showed consistent administration of the antibiotic during the relevant period. A third resident, with a history of schizophrenia, seizure disorder, anxiety, depression, and diabetes, was incorrectly coded on the MDS as receiving antiplatelet and diuretic medications. Review of the medical record showed that the diuretic had been discontinued well before the assessment period, and there were no active orders for antiplatelet therapy at any time. The MDS assessment, however, documented the resident as receiving these medication classes, which was not supported by the resident's current medication orders.
Failure to Refer Resident with Schizophrenia for PASRR Level II Evaluation
Penalty
Summary
Facility staff failed to refer a resident with a documented diagnosis of Schizophrenia for a PASRR Level II evaluation, as required for individuals with major mental disorders. The Level I PASRR screening indicated the presence of Schizophrenia and the need for further assessment, but a contradictory check mark was placed indicating a negative screen for serious mental illness, and no further action was taken. The resident was admitted with multiple diagnoses, including Schizophrenia, and was prescribed and administered antipsychotic medication for this condition since admission. Despite the resident's ongoing need for psychotropic medication and a care plan addressing Schizophrenia, staff did not complete the required Level II PASRR referral when the resident's stay was extended from short-term to long-term care. During an interview, a staff member acknowledged awareness of the requirement and attributed the failure to complete the referral to time constraints, confirming that the responsibility for the referral lay with the Social Worker upon admission or transition to long-term care.
Failure to Provide Functioning Hearing Aids as Outlined in Care Plan
Penalty
Summary
Facility staff failed to implement a care plan intervention for a resident with bilateral hearing loss, vascular dementia, and paroxysmal atrial fibrillation. The resident's care plan, last reviewed on 06/07/23, specified the need for functioning bilateral hearing aids and required staff to ensure the availability and proper use of adaptive communication equipment. Despite a physician's order for an audiology evaluation and treatment, the resident did not have access to working hearing aids. Instead, the family provided alternative devices, such as a microphone system and a pocket talker, but these were either removed by the facility or found to be ineffective. Observations and interviews revealed that the resident was unable to locate her hearing aids and reported that they did not work. Staff members, including a CNA, RN, and unit manager, were either unaware of the resident's hearing aids or believed that an amplifier provided by the family was being used as a substitute. The facility did not ensure the resident had access to functioning hearing aids as outlined in the care plan, resulting in a failure to meet the resident's assessed communication needs.
Failure to Revise Care Plan for Ongoing Noncompliant PPE Use
Penalty
Summary
Facility staff failed to revise and update the comprehensive care plan for a resident who consistently exhibited the behavior of wearing gloves and double masks throughout the facility, despite ongoing staff redirection. The care plan, initially created to address non-compliance with PPE use, included interventions such as approaching the resident calmly, encouraging removal of gloves for safety, and redirecting to wear a single mask. However, there was no documented evidence that these interventions were reviewed or revised to address the resident's continued behavior, as required by regulations. Observations and staff interviews confirmed that the resident, who had a history of depressive disorder, anxiety, dementia, and substance abuse, was repeatedly seen wearing gloves and two masks in various areas of the facility, including while carrying soiled incontinence items. Staff acknowledged the ongoing nature of the behavior and the need for care plan updates, but no revisions were made to reflect the resident's current actions. The deficiency was identified through direct observation, record review, and staff interviews.
Failure to Ensure Resident Access to Functional Hearing Aids
Penalty
Summary
Facility staff failed to ensure that a resident with bilateral hearing loss received the necessary care and services to maintain their ability to perform activities of daily living. The resident, who had a history of hearing impairment and used bilateral hearing aids, was admitted with multiple diagnoses including hearing loss, vascular dementia, and paroxysmal atrial fibrillation. Documentation showed that one of the resident's hearing aids was broken, and although the family intended to arrange for repairs, there was no evidence that the facility staff assisted in acquiring or ensuring the use of functioning hearing aids. The care plan specifically required staff to ensure the availability and functioning of adaptive communication equipment, including hearing aids, but this was not followed. Observations and interviews revealed that the resident did not have working hearing aids and was using alternative devices provided by the family, such as an amplifier and a pocket talker, which were reportedly ineffective. Staff members interviewed were either unaware of the resident's hearing aid status or believed the amplifier was a substitute for hearing aids. There was no documented evidence in the medical record that staff facilitated the acquisition or use of hearing aids, despite physician orders for audiology evaluation and follow-up. The lack of appropriate assistive devices and staff action resulted in the resident's diminished ability to communicate and perform daily activities.
Failure to Provide Restorative Nursing Services for Resident with Limited Range of Motion
Penalty
Summary
Facility staff failed to provide appropriate restorative nursing care for a resident with limited range of motion (ROM) following discharge from occupational therapy. The resident, who had diagnoses including hemiplegia, hemiparesis, and muscle weakness, was care planned to receive active assistive ROM exercises for the lower extremities six days per week, with the goal of improving exercise ability. The occupational therapy discharge summary recommended continued participation in a restorative plan to decrease the risk of decline. However, after the resident was discharged from OT, the resident was not listed on the facility's restorative nursing program documentation, and there was no evidence that restorative services were provided during a 13-day period. Interviews with facility staff revealed that the process for transferring restorative orders from therapy to the restorative nursing program was disrupted due to the restorative nurse being out on medical leave, resulting in delays in entering orders into the electronic health record system. As a result, the resident did not receive the restorative nursing interventions as ordered and care planned, and there was a failure to ensure the resident received necessary treatment and services to maintain or improve ROM.
Failure to Prevent Elopement Due to Inadequate Supervision and Unsecured Exits
Penalty
Summary
Facility staff failed to adequately monitor and supervise a resident with a known history of elopement and exit-seeking behaviors, resulting in the resident eloping from the facility. The resident, who had diagnoses including dementia, bipolar disorder, and behavioral disturbances, had multiple care plans and physician orders in place indicating a high risk for elopement, including the use of a Wander Guard device and hourly location checks. Despite these interventions, documentation and staff interviews revealed lapses in supervision and monitoring, particularly during shift changes and after a fire drill, when doors were not properly secured. On the evening of the incident, the resident was last seen in his room by nursing staff, but subsequent rounds failed to locate him. Staff did not immediately escalate the situation according to facility policy, which required prompt notification of supervisors and administration when a resident at risk for elopement could not be found. There were inconsistencies in documentation, including identical vital signs recorded on different days, and a delay in initiating a facility-wide search and notifying the DON and administrator. The Code Pink (elopement alert) was not called until a significant amount of time had passed after the resident was discovered missing. The facility's investigation found that the doors were not secured following a fire drill, which contributed to the resident's ability to leave undetected. Staff interviews indicated a lack of clear communication during shift handoff and a delay in recognizing and responding to the resident's absence. The combination of inadequate supervision, failure to follow established elopement protocols, and unsecured exits directly led to the resident's elopement.
Failure to Provide Proper Catheter Care to Prevent UTI
Penalty
Summary
Facility staff failed to provide appropriate care to prevent urinary tract infections for a resident with an indwelling Foley catheter. The resident, who was admitted with multiple diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms and had severely impaired cognitive skills, was observed lying in bed with the Foley catheter connection tube and drainage bag placed on the floor. The care plan for this resident included specific interventions such as checking for wetness, monitoring for changes in urine characteristics, and reporting abnormalities, but these were not followed as evidenced by the improper placement of the catheter equipment during the observation. Employee #4, the unit manager, acknowledged at the time of observation that the staff did not provide the required care, treatment, and services to prevent urinary tract infections as outlined in the resident's care plan.
Failure to Follow Insulin Administration Protocols and Infection Control Practices
Penalty
Summary
A registered nurse failed to demonstrate appropriate competencies and skills in administering insulin to a resident with Type 2 Diabetes Mellitus, hypoglycemia, and metabolic encephalopathy. The nurse was observed carrying an insulin syringe into the resident's room, stating he was about to administer 6 units of insulin based on a recent blood sugar reading of 317 mg/dl. The nurse administered the insulin five hours before the scheduled time, without consulting the medical doctor as required by the physician's order, and did not use the prescribed Lyumjev KwikPen device. Instead, he used a syringe to withdraw insulin from the pen, contrary to manufacturer instructions, which specifically prohibit this practice due to the risk of overdose. The nurse also failed to follow infection control protocols. After administering the insulin, he exited the resident's room still wearing the same gloves, holding the used syringe with the needle exposed, and walked down the hallway to the medication cart. He then discarded the syringe in the sharps container and proceeded to touch the computer and unlock the medication cart without removing his gloves or performing hand hygiene, as required by facility policy. Additionally, the nurse did not ensure that the medication cart was visible during medication administration, as stipulated in the facility's policy. These actions were observed and confirmed through staff interviews and record review. The facility's policies and the insulin manufacturer's guidelines were not followed, resulting in a failure to provide safe and appropriate nursing services for the resident. The resident did not experience any harm or ill effects from this incident.
Failure to Document and Review Pharmacist Recommendations in Medical Records
Penalty
Summary
Facility staff failed to ensure that pharmacist recommendations from monthly drug regimen reviews were properly documented in the residents' medical records and reviewed by the physician, as required by facility policy. For one resident with diagnoses including diabetes, heart failure, and dementia, documentation of the pharmacist's recommendations and the physician's responses for three months was not present in the electronic health record. Although paper copies of these documents were found in a unit manager's office, they had not been uploaded to the resident's official medical record. In another case, a resident with multiple psychiatric and neurological diagnoses, including dementia and seizure disorder, had no documented evidence in the medical record that the physician received, reviewed, or responded to the pharmacist's recommendations from a monthly medication review. The pharmacist's recommendations were noted as given to the interdisciplinary team, but the specific recommendations and any physician response were missing from the resident's record. Interviews with staff confirmed that the process for uploading or scanning pharmacist recommendations and physician responses into the electronic health record was not consistently followed. In both cases, the lack of documentation in the residents' medical records constituted a failure to comply with facility policy and regulatory requirements for medication regimen review and physician follow-up.
Insulin Administration Not Per Physician Order or Manufacturer Instructions
Penalty
Summary
Facility staff failed to administer medication in accordance with both physician orders and manufacturer specifications for one resident with Type 2 Diabetes Mellitus, hypoglycemia, and metabolic encephalopathy. The resident had a physician's order for Lyumjev Insulin to be administered via KwikPen, subcutaneously, twice daily at specific times, using a sliding scale based on blood glucose readings. The order also specified that the insulin should be administered at 6:00 AM and 9:00 PM, and the manufacturer's instructions explicitly stated not to use a syringe to withdraw insulin from the prefilled pen. During an observation, a registered nurse was seen preparing to administer insulin to the resident using a syringe to aspirate the medication from the Lyumjev KwikPen, rather than using the pen as intended. The nurse administered 6 units of insulin based on a blood sugar reading of 317 mg/dl, but did so approximately five hours before the scheduled administration time. The nurse admitted to not consulting the physician before making this decision and acknowledged that it was not within his scope of practice to alter the administration schedule or method without physician input. The nurse also failed to follow proper infection control procedures by walking through the hallway with a used syringe, discarding it only after returning to the medication cart, and continuing to touch surfaces with contaminated gloves. The incident was witnessed by a surveyor and brought to the attention of facility leadership. The resident did not experience any harm as a result of this incident.
Failure to Provide Resident with Diet Meeting Nutritional Needs and Preferences
Penalty
Summary
Facility staff failed to provide a resident with a diet that met daily nutritional and special dietary needs, specifically neglecting the resident's preferences for fresh fruits and vegetables. The resident, who had multiple diagnoses including diabetes mellitus type 2, anemia, and protein calorie malnutrition, repeatedly expressed dissatisfaction with the quality and content of the food served, comparing it to that of a soup kitchen and noting the lack of fresh produce and excessive starch. Despite a care plan intervention to honor food preferences and provide double portions, the resident reported missing menu items, such as not receiving baked ziti or adequate fresh fruit, and not being provided with butter or sugar as requested. Observations and interviews confirmed that the resident was not offered fresh fruit or snacks after breakfast, even though fresh fruit was available on the unit. Staff interviews revealed a lack of clarity and follow-through regarding the provision of fresh fruits and vegetables, with the kitchen director and unit manager both acknowledging the availability of these items but unable to explain why the resident did not receive them. The DON acknowledged the findings, confirming the deficiency in meeting the resident's dietary needs and preferences.
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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