Stoddard Baptist Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Washington, District Of Columbia.
- Location
- 1818 Newton St. Nw, Washington, District Of Columbia 20010
- CMS Provider Number
- 095020
- Inspections on file
- 15
- Latest survey
- April 21, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Stoddard Baptist Nursing Home during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments, who required a two-person assist for transfers, was moved from a wheelchair to a bed by a CNA without the required help. The CNA did not remove the wheelchair footrests and attempted a quick transfer to avoid contact with feces, resulting in the resident sustaining facial and leg injuries. The resident was hospitalized for a right leg hematoma that developed necrosis and required surgical intervention. Documentation confirmed the resident had no prior wounds and that the care plan required a two-person assist, which was not followed.
Facility staff did not report an allegation of abuse involving two residents after an altercation resulted in one resident sustaining scratches, with the incident documented several days before it was reported to the State agency. The injured resident had severe cognitive impairment, and the other resident exhibited aggressive behaviors and was later transferred for psychiatric reasons. Staff interviews indicated a lack of awareness regarding mandatory reporting requirements for such incidents.
Facility staff did not develop a care plan addressing a resident's need for a 2-person physical assist during transfers, despite MDS assessment findings and the resident's medical conditions. After a transfer, the resident was found with bleeding and a hematoma, and staff interviews confirmed the care plan lacked documentation of the required assistance level.
Facility staff failed to prevent a resident's pressure ulcer from developing to Stage 3. Despite orders for skin protection and weekly assessments, the resident's new ulcer was not promptly communicated to the primary care physician, resulting in a delay of over 48 hours before new interventions were implemented. Interviews revealed a lack of communication and proper skin assessments by the nursing staff and Medical Director.
Facility staff failed to ensure effective pain assessments and evaluations for a resident with a known left hip fracture. Despite the resident's complaints of pain and x-ray results indicating a fracture, staff did not consistently document or assess pain characteristics and failed to notify the primary care physician promptly.
Facility staff failed to maintain sanitary conditions for food service, with hot food temperatures below 135°F, soiled cooking equipment, unlabeled ready-to-eat foods, improper thawing of chicken, and inadequate sanitize water solution in the three-compartment sink.
Facility staff failed to conduct thorough investigations for four residents, including incidents of elopement, staff abuse, and verbal threats. The investigations lacked documentation of findings, interviews, and assessments as required by facility policies.
Facility staff failed to immediately notify a resident's primary physician and representative of a sacral pressure ulcer and another resident's hip fracture. Despite documentation of the conditions, there was a significant delay in communication, revealing lapses in the notification protocol.
A resident with multiple diagnoses and a risk for elopement left the facility undetected due to inadequate monitoring and a security guard leaving his post unattended. The resident was found at a bus stop by the police and returned to the facility. The incident was not documented in the security logbook.
The facility staff failed to implement policies and procedures for reporting and investigating allegations or incidents of abuse and neglect for four residents. Incidents included a resident eloping, a physical altercation between two residents, and an allegation of staff abuse, all of which were not properly reported or investigated.
The facility failed to report the results of investigations to the State Agency within 5 working days for two residents. One resident eloped, and another alleged abuse, but the facility lacked documented evidence and could not locate additional documentation due to leadership changes.
Facility staff failed to provide written information to a resident's representative specifying the duration of the state bed-hold policy before the resident's transfer to the hospital. Despite the facility's policy requiring such notifications, there was no documented evidence that it was provided. Interviews revealed a lack of clarity and accountability regarding the notification process during off-hours or weekends.
Facility staff failed to complete a quarterly MDS assessment for a resident with multiple diagnoses, including a Stage 3 Pressure Ulcer, within the required 14-day window. The assessment was completed 3 days late, as confirmed by the Director of MDS Support Systems.
Facility staff failed to document a resident's cognitive patterns in the MDS Assessment. The resident, admitted with Cerebral Infarction and Multiple Sclerosis, had an incomplete Annual MDS assessment with blank sections for the Brief Interview for Mental Status (BIMS). The Director of Social Services acknowledged the oversight 38 days post-admission.
Facility staff failed to develop care plans for a resident's IV line and cholecystectomy tube and did not implement fall prevention interventions for another resident. The Director of Nursing and an LPN acknowledged these deficiencies.
A resident with multiple diagnoses and a risk for elopement left the facility undetected due to a security guard leaving his post unattended. The resident was found at a bus stop by the police and returned to the facility. The incident was not properly documented in the security logbook, and the security guard admitted to not following proper procedures.
Facility staff failed to follow the physician's order to change a resident's PICC line dressing weekly. Despite documentation indicating otherwise, the dressing was not changed for 24 days. The DON acknowledged the discrepancy and confirmed that the nurses had documented actions they did not complete.
Facility staff failed to ensure that empty oxygen tanks were not stored with full oxygen tanks intended for patient use. Observations revealed empty tanks stored with full tanks on both the 1st and 2nd floors. Staff were unsure about the storage policy, and the DON confirmed the facility lacked a clear procedure for oxygen tank storage.
Facility staff failed to promptly notify the physician of a resident's hip fracture identified in x-ray results. The day shift nurse only reported knee results, and the night shift staff did not notify the physician or representative. The physician was informed 21 hours later, leading to the resident's transfer to the emergency room.
Facility staff failed to ensure that the Nurse Staffing Agency used to supplement nursing staff was operating with a valid business license. The agency provided services in D.C. on an expired license, and the facility used 14 nursing staff from the agency for approximately 150 shifts. The DON and Chief Human Resources Officer were unaware of the expired license until the State Surveyors' visit.
Facility staff failed to accurately document in the medical records of three residents. One resident's central line dressing change was not performed as documented, another resident's sacral pressure ulcer stage was incorrectly recorded, and a third resident's emergency room visit was not accurately reflected in the monthly summary report. The DON acknowledged these discrepancies.
Facility staff failed to document annual reviews for 12 out of 25 Infection Control policies and procedures. The Infection Preventionist acknowledged the absence of review dates and committed to updating the policies based on national standards and the facility's assessment.
Facility staff failed to document that two residents or their responsible parties received education on the benefits and potential side effects of the Influenza vaccine. Both residents, who had severely impaired cognitive status, received the vaccine without the required education being provided or documented.
Facility staff failed to maintain essential equipment in safe condition. One food pellet warmer was inoperative, and two of the four burners on one gas stove did not light up when tested. These issues were confirmed by a staff member.
Failure to Provide Required Assistance During Transfer Results in Resident Injury
Penalty
Summary
Facility staff failed to provide adequate assistance during a transfer of a resident from a wheelchair to a bed, resulting in the resident sustaining injuries that required hospitalization. The resident, who had diagnoses including unspecified dementia, chronic atrial fibrillation, and muscle weakness, was assessed as dependent on staff for transfers and required a two-person physical assist. Despite this documented need, a certified nurse aide (CNA) attempted to transfer the resident alone, without the required assistance. During the transfer, the CNA did not remove the wheelchair footrests and attempted to move the resident quickly to avoid soiling her clothes due to the resident's incontinence episode. As a result, the resident struck his face and sustained a hematoma to the right lower leg. The resident was found bleeding from the nose and mouth, and a hematoma was noted on the right leg. The resident was subsequently transferred to the emergency room, where further evaluation revealed a right lower extremity hematoma with necrosis, requiring surgical debridement and wound vac placement. Prior to the incident, the resident had no documented skin issues or wounds, and regular skin assessments indicated skin integrity was intact. The CNA involved admitted to transferring the resident alone and not following proper safety protocols, including neglecting to remove the wheelchair footrests. The incident was reported to the state agency, and facility documentation confirmed that the resident's care plan and assessments required a two-person assist for transfers, which was not followed at the time of the event.
Failure to Timely Report Resident-to-Resident Altercation and Abuse Allegation
Penalty
Summary
Facility staff failed to report an allegation of abuse involving a resident-to-resident altercation to the State agency within the required timeframe. The incident was first documented on 02/25/25 when one resident was found with two scratches on his left hand following a verbal altercation with his roommate. Initial interviews with both residents did not reveal the cause of the scratches, and the injured resident initially denied knowing how the injury occurred. The incident was not reported to the State agency until 03/03/25, several days after the initial documentation and after further interviews revealed that the resident had been in a fight with his roommate. The resident who sustained the scratches had a history of severe cognitive impairment, as indicated by a low BIMS score, and multiple medical diagnoses including dementia and traumatic brain injury. Medical records show that the scratches were superficial, with no active bleeding, and were treated according to physician orders. The roommate involved in the altercation was also documented as having dementia and behavioral disturbances, and was later transferred from the facility due to a psychiatric emergency following combative and aggressive behavior toward staff and other residents. Despite documentation of these behaviors and the altercation, the facility did not make timely notifications to the State agency or the ombudsman office as required by policy. Staff interviews revealed a lack of understanding regarding the requirement to report even verbal altercations as potential abuse. The Director of Nursing stated that they were unaware that a verbal altercation needed to be reported. The delay in reporting and incomplete notifications were contrary to the facility's own policy, which requires immediate reporting of suspected abuse, including resident-to-resident incidents, to the appropriate authorities within specified timeframes.
Failure to Develop Care Plan for 2-Person Transfer Assist
Penalty
Summary
Facility staff failed to develop a care plan that addressed a resident's need for a 2-person physical assist during transfers from wheelchair to bed. The resident, who had diagnoses including unspecified dementia, chronic atrial fibrillation, and muscle weakness, was assessed in the State Minimum Data Set (MDS) as requiring extensive assistance from two staff members for transfers. However, a review of the resident's care plan revealed no documented evidence specifying this requirement for a 2-person assist during transfers. An incident occurred in which a nursing assistant, after transferring the resident to bed, observed bleeding from the resident's mouth and nose, and a hematoma on the right lower leg. Staff interviews confirmed that the MDS assessment indicated a need for a 2-person assist, but the care plan did not reflect this. The Director of Nursing referenced physical therapy notes suggesting a one-person assist but acknowledged that a significant change MDS assessment had not been completed.
Failure to Prevent and Address Pressure Ulcer Development
Penalty
Summary
Facility staff failed to ensure that a resident received care to prevent the development of a pressure ulcer, which was first observed at Stage 3. The resident, who had a history of Adult Failure to Thrive, History of Falling, and Muscle Weakness, was admitted to the facility and had several physician's orders for skin protection and weekly skin assessments. Despite these orders, the resident's medical record lacked documented evidence of proper skin assessments and timely notification to the primary care physician about the new Stage 3 sacral pressure ulcer observed on 02/28/24. The resident's medical record showed that skin assessments were documented as normal on multiple occasions, including the day before the Stage 3 ulcer was identified by the Wound Care Physician. The Wound Care Physician documented a treatment order for the new ulcer, but there was no evidence that the primary care physician was notified immediately, resulting in a delay of over 48 hours before new orders or interventions were implemented. This delay in care contributed to the actual harm experienced by the resident. Interviews with facility staff, including the Director of Nursing and the Medical Director, revealed that the nursing staff did not communicate any skin issues to the primary care physician during their assessments. The Medical Director also did not perform a skin assessment during their visit with the resident. The facility's failure to follow its own policies and procedures for pressure ulcer prevention and care led to the development and progression of the resident's pressure ulcer to Stage 3, causing actual harm.
Failure to Provide Effective Pain Management for Resident with Hip Fracture
Penalty
Summary
Facility staff failed to ensure that a resident with a known left hip fracture received effective pain assessments and evaluations. The resident, who had a history of muscle weakness, gait abnormalities, and age-related physical debility, fell and sustained a left hip fracture. Despite the resident's complaints of pain and the x-ray results indicating a fracture, the staff did not consistently document or assess the pain characteristics such as intensity, pattern, frequency, and duration as required by the facility's pain management policy. The report highlights multiple instances where staff failed to notify the resident's primary care physician about the x-ray results showing a left hip fracture. On several occasions, staff documented that they had received the x-ray results but did not inform the physician or the resident's representative. Additionally, the facility lacked an on-call schedule for medical providers, leading to delays in communication and inadequate pain management for the resident. Interviews with staff revealed that there was confusion and inconsistency in following the protocol for notifying medical providers about critical results. The night shift supervisor admitted to not calling physicians during the night unless it was an emergency, while the medical director stated that any abnormal results affecting the resident's well-being should be reported immediately. This lack of clear communication and adherence to protocols contributed to the deficiency in providing appropriate pain management for the resident.
Food Safety and Sanitation Deficiencies
Penalty
Summary
Facility staff failed to serve foods under sanitary conditions, as evidenced by hot food temperatures that were below the required 135 degrees Fahrenheit on six observations. Specifically, puree hot foods such as chicken (106.5°F), spinach (104.1°F), and potatoes (105.8°F), as well as regular hot foods like fried chicken (134.4°F), spinach (114.4°F), and potatoes (106.6°F), were all found to be inadequately heated. Additionally, cooking equipment, including two convection ovens and two grease fryers, were observed to be soiled with cooked food residue. Ready-to-eat foods, such as open packs of cold cuts, shredded yellow cheese, sliced yellow cheese, feta cheese, and a jar of applesauce stored in the walk-in refrigerator, were not labeled with a use-by date. Furthermore, pieces of chicken were improperly thawed in a sink full of stagnant water. The sanitize water solution in the three-compartment sink tested below the recommended 200 parts per million (PPM), measuring less than 100 PPM. These observations were confirmed by a staff member during an interview.
Failure to Conduct Thorough Investigations
Penalty
Summary
Facility staff failed to have documented evidence that they conducted thorough investigations for four residents. For Resident #192, the facility did not document the findings of their search in various areas as outlined in their Missing Resident policy, nor did they determine if neglect occurred or interview all relevant staff and family members. The resident had eloped from the facility and was found by the police, but the investigation lacked thoroughness and completeness as per the facility's policies. For Resident #294, the facility did not conduct a thorough investigation into the resident's allegation of staff abuse. The investigation packet lacked evidence of a resident assessment, physician notification, and interviews with all staff present at the time of the alleged incident. The resident had reported hitting his head on the bed rail three times during care, but the facility did not follow through with a comprehensive investigation. For Resident #244, the facility failed to thoroughly investigate an allegation of a verbal threat of harm by Resident #63. The investigation documents did not include interviews or statements from the involved residents or staff present at the time of the incident. The incident involved Resident #63 making a verbal threat to shoot Resident #244, which led to police intervention. However, the facility did not document a thorough investigation as required by their policies.
Failure to Notify Physicians and Representatives of Significant Changes
Penalty
Summary
Facility staff failed to immediately notify Resident #52's primary physician and their representative of a facility-acquired sacral pressure ulcer. Resident #52, who was admitted with diagnoses including Adult Failure to Thrive, History of Falling, and Weakness, developed a stage 3 sacral decubitus ulcer. Despite the wound being documented by the Wound Care Physician on 02/28/24, there was no evidence that the primary care physician or the resident's representative was notified within the following 48 hours. The Director of Nursing acknowledged the lapse in protocol during an interview on 03/06/24. Facility staff also failed to immediately notify Resident #243's primary physician or their representative of an x-ray result showing a left hip fracture. Resident #243, admitted with diagnoses including Muscle Weakness and Age-Related Physical Debility, fell on 05/29/23, and an x-ray was ordered. The x-ray results, received on 05/30/23, indicated a fracture of the neck of the proximal femur. However, the assigned day shift nurse did not notify the physician or the resident's representative. The night shift staff also failed to notify the physician or representative, and it was not until 05/31/23 that the primary care physician and the resident's representative were informed. Interviews with staff revealed a lack of clarity and adherence to the notification protocol. The night shift nursing supervisor mentioned that there was no on-call list and that they were instructed not to call medical doctors during the night unless it was an emergency. The Medical Director, however, stated that he was available 24/7 and that any significant changes affecting a resident's well-being should be reported immediately. The Director of Nursing acknowledged the findings but did not provide further comments.
Resident Elopement Due to Inadequate Monitoring and Security Lapse
Penalty
Summary
Facility staff failed to ensure a resident was free from neglect, as evidenced by the resident leaving the facility without staff knowledge. The resident, who had multiple diagnoses including encephalopathy, seizures, muscle weakness, and cirrhosis of the liver, was identified as having a risk for elopement. Despite a care plan that included monitoring the resident's movements closely, the resident managed to leave the facility undetected. The incident occurred early in the morning when the resident was last seen in his room at 5:30 AM and was discovered missing at 6:40 AM. A Code Pink was initiated, and the police were called. The resident was eventually found at a bus stop by the police and returned to the facility after much encouragement. The investigation revealed that the security guard on duty left his post unattended, which allowed the resident to exit the facility through the front door. The security guard admitted to leaving his post to go into a closet behind the security desk and acknowledged that he should have called another security guard to cover his post. The security logbook lacked documented evidence of the resident's elopement incident, and the security supervisor confirmed that the incident should have been documented. Staff interviews and record reviews indicated that the resident had an intact cognitive status and required supervision for activities of daily living. The resident expressed a desire to leave the facility and stated that he would walk out again. The psychiatric nurse practitioner noted that the resident did not present with any psychiatric disorder but appeared to make poor and irrational judgments occasionally. The facility's failure to monitor the resident adequately and the security guard's negligence in leaving his post unattended contributed to the resident's elopement.
Failure to Implement Abuse and Neglect Policies
Penalty
Summary
The facility staff failed to implement its policies and procedures for reporting and investigating allegations or incidents of abuse and neglect for four residents. Resident #192 eloped from the facility without staff knowledge, and the incident was not properly reported or investigated. The resident was found by the police and returned to the facility, but the staff did not follow the necessary protocols for reporting and investigating the incident, as confirmed by the Director of Nursing (DON). The resident's medical record and the facility's documentation lacked evidence of a thorough investigation and proper reporting to the relevant authorities. In another incident, the facility staff failed to report and investigate a physical altercation between Resident #40 and Resident #25. The altercation was observed by two State Agency Surveyors, but there was no documented evidence in the medical records of either resident that the incident was noted or investigated. Interviews with staff revealed that Resident #25 had a history of erratic behavior and had previously hit other residents and staff. Despite this, the necessary protocols for reporting and investigating the incident were not followed. Additionally, the facility staff failed to implement its policies and procedures for reporting and investigating an allegation of staff abuse made by Resident #294. The resident alleged that a staff member hit his head on the wall three times during care. The facility's investigation lacked documented evidence of a thorough assessment, notification of the physician, and interviews with all relevant staff and other residents. The DON confirmed that the facility leadership had changed, and additional documentation concerning the allegation could not be located.
Failure to Report Investigation Results Timely
Penalty
Summary
The facility staff failed to report the results of their investigations to the State Agency within 5 working days for two residents. Resident #192, who had multiple diagnoses including encephalopathy and seizures, eloped from the facility. The incident was reported to the State Agency, but the facility's investigation packet lacked documented evidence describing the results of the investigation. During an interview, the Director of Nursing confirmed that the results of the investigation were not documented. Resident #294, who had multiple diagnoses including hemiplegia and diabetes mellitus type 2, alleged that his head was hit on the wall three times during care. The incident was reported to the State Agency, and a follow-up submission was made 10 days later, stating that there was no evidence of abuse or neglect. However, the Director of Nursing was unable to locate any additional documentation concerning the allegation due to changes in facility leadership. The facility's failure to report the results of these investigations within the required timeframe constitutes a deficiency. The lack of documented evidence and the inability to locate additional documentation highlight the facility's non-compliance with reporting requirements, as specified in their policy on the prohibition of resident abuse and abuse prevention.
Failure to Provide Bed-Hold Notification
Penalty
Summary
Facility staff failed to provide written information to Resident #66's representative specifying the duration of the state bed-hold policy before the resident's transfer to the hospital. The facility's Bed Hold policy mandates that the admissions office mail out the Bed Hold notification form to each resident or their point of contact each time they are out of the facility, with the form being mailed out the next business day. However, in this case, there was no documented evidence that such a notification was provided to Resident #66's representative. The resident, who had diagnoses including Dementia, Hypertension, and Hyperlipidemia, was transferred to the hospital due to severe health issues, including fever, nausea, vomiting, and bloody discharge from the urethra. Despite the transfer and subsequent hospital admission, the facility failed to follow its own policy regarding bed-hold notifications. Interviews with facility staff revealed a lack of clarity and accountability regarding who is responsible for providing bed-hold notifications during off-hours or weekends. The Social Services Director indicated that the Admissions Department handles the notifications, but was unsure about the process during non-business hours. The Admissions Director and Director of Sales and Marketing confirmed that the process involves reviewing nurse's notes and physician's orders to identify transferred residents, followed by generating a notification form during weekday meetings. However, they could not explain why the notification for Resident #66 was not completed, admitting that the process had failed in this instance.
Failure to Complete Quarterly MDS Assessment on Time
Penalty
Summary
Facility staff failed to complete a quarterly Minimum Data Set (MDS) assessment for one of the sampled residents, identified as Resident #72. The resident was admitted with diagnoses including Pressure Ulcer of Sacral Region, Stage 3, Dysphagia, Aphasia, Pain, and Cerebral Infarction. The facility had a contract with an external company, effective on 02/12/24, to manage MDS assessments. However, the quarterly MDS assessment for Resident #72, with an assessment reference date (ARD) of 02/16/24, was not completed within the required 14-day window, making it late by 3 days. During a telephone interview, the Director of MDS Support Systems confirmed that the assessment was considered late as it was completed on 03/04/24, beyond the 14-day window from the ARD. The review of the MDS transmittal sheet showed that while the annual MDS assessment was accepted by CMS, the quarterly assessment was still in progress and not completed on time. This failure to complete the quarterly MDS assessment within the required timeframe constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Complete Cognitive Patterns in MDS Assessment
Penalty
Summary
Facility staff failed to have documented evidence that a resident's Admission Minimum Data Set (MDS) Assessment was completed, specifically by not coding the resident's cognitive patterns in Section C. The resident, who was admitted with diagnoses including Cerebral Infarction and Multiple Sclerosis, had an Annual MDS assessment that indicated the Brief Interview for Mental Status (BIMS) should be conducted. However, sections C0200, C0400, and C0500 were left blank, and there was no documented evidence of the resident's BIMS summary score. During an interview, the Director of Social Services confirmed that it was her responsibility to complete Section C on the day of admission or the next day, but this had not been done 38 days after the resident's admission.
Failure to Develop and Implement Care Plans
Penalty
Summary
Facility staff failed to develop care plans with goals and approaches for a resident's use of a central intravenous (IV) line and a cholecystectomy tube. The resident was readmitted to the facility with a central line and a cholecystostomy tube, but 22 days after readmission, there was no documented evidence that a comprehensive care plan had been developed to address these needs. The Director of Nursing acknowledged that these care plans should have been started upon readmission. Facility staff also failed to implement a resident's care plan interventions for falls. The resident was found on the floor with a small cut on her head, and during an observation, it was noted that the call light was not within the resident's reach, and the floor mat was not properly placed. The resident's care plan included specific interventions such as keeping the call light within reach and placing floor mats at the bedside, but these were not followed. The Licensed Practical Nurse acknowledged the findings and corrected the placement of the call light and floor mat during the observation.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility's staff failed to provide adequate supervision for a resident, resulting in the resident leaving the facility without staff knowledge. The resident, who had multiple diagnoses including encephalopathy, seizures, muscle weakness, and cirrhosis of the liver, was identified as having a risk for elopement. Despite a care plan that included monitoring the resident's movements closely, the resident was able to leave the facility undetected. The incident occurred early in the morning when the resident was last seen in his room at 5:30 AM and was discovered missing at 6:40 AM. A search was initiated, and the resident was eventually found at a bus stop by the police and returned to the facility after much encouragement. The investigation revealed that the security guard on duty at the time left his post unattended, allowing the resident to exit the facility through the front door. The security guard admitted to leaving his post to go into a closet behind the security desk and acknowledged that he should have called another security guard to cover his post. The security logbook lacked documented evidence of the resident's elopement incident, and the security guard's actions were found to be in violation of the facility's policy. Interviews with staff and review of the facility's investigation packet confirmed that the security guard did not follow proper procedures, and the incident was not properly documented in the security logbook. The nursing supervisor and other staff members were involved in the search for the resident, and the resident's family was notified. The resident was found to be alert and oriented upon return but expressed a desire to leave the facility again. The psychiatric team was involved in reassessing the resident's elopement risk and monitoring the resident closely.
Failure to Follow Physician's Order for PICC Line Dressing Change
Penalty
Summary
Facility staff failed to follow the physician's order to change a resident's peripherally inserted central catheter (PICC) line dressing every Friday. The resident, who had multiple diagnoses including retention of urine, hypertension, and dementia, was readmitted to the facility with a central line placed on the right upper arm. Despite the physician's order to change the PICC line dressing weekly, the dressing was not changed from the time of the resident's readmission on 02/09/24 until 03/04/24, a span of 24 days. The Treatment Administration Record (TAR) falsely indicated that the dressing had been changed on three separate Fridays during this period. An observation on 03/04/24 revealed that the dressing was still dated 02/09/24, and a Licensed Practical Nurse (LPN) confirmed that only a Registered Nurse (RN) was allowed to change the dressing. The Director of Nursing (DON) acknowledged that the physician's order was not followed and that the nurses had documented actions they did not complete. This failure to adhere to the physician's order and the facility's policy for PICC line dressing changes was identified as a deficiency.
Improper Storage of Oxygen Tanks
Penalty
Summary
Facility staff failed to ensure that empty oxygen tanks were not stored in the same area as full oxygen tanks intended for patient use. During an observation of the 2nd floor oxygen storage room, one empty oxygen tank was found stored with four full oxygen tanks. Employee #22, an LPN, stated that a nurse is supposed to check the tank before using it for a resident, and empty tanks are supposed to be kept in the basement for pickup. However, the facility did not have a clear policy or procedure for the storage of oxygen tanks. A similar issue was observed in the 1st floor oxygen storage room, where two empty oxygen tanks were stored with three full oxygen tanks. Employee #7, another LPN, was unsure about the storage policy and referred to the DON for clarification. The DON acknowledged the findings and confirmed that the facility lacked a policy for oxygen tank storage. The DON mentioned that best practice would be for the person checking the code carts to ensure only full tanks are in the storage room.
Failure to Promptly Notify Physician of Critical X-Ray Results
Penalty
Summary
Facility staff failed to promptly notify the ordering physician of radiology results for a resident who fell and sustained a fracture. Resident #243, who had mild cognitive impairment and no prior falls, fell while attempting to hug another resident. The physician ordered x-rays for the resident's left hip and knee, which were conducted the following day. The x-ray results indicated a fracture of the neck of the proximal femur, but the day shift nurse only reported the knee results to the Physician's Assistant and did not inform them of the hip fracture. The night shift nurse and nursing supervisor both documented the fracture in their notes but did not notify the resident's physician or representative. It was not until the following day, approximately 21 hours later, that the primary care physician and the resident's representative were informed of the x-ray results. The resident was then transferred to the nearest emergency room for further evaluation. Interviews with the involved staff revealed a lack of clarity and communication regarding the notification process for critical results. The night shift nursing supervisor mentioned that there was no on-call list and that they were instructed not to call medical doctors during the night unless it was an emergency. The Medical Director, however, stated that he was available 24/7 and that any critical results affecting a resident's well-being should be reported immediately.
Use of Nurse Staffing Agency with Expired Business License
Penalty
Summary
Facility staff failed to provide documented evidence that the Nurse Staffing Agency used to supplement the facility's nursing staff was operating in compliance with applicable Federal, State, and local laws and regulations. The Nurse Staffing Agency provided services in the District of Columbia on an expired business license. The facility's census on the first day of the survey was 90. A review of the Staffing Agency's business license revealed an expiration date, and the facility continued to use the agency's services beyond this date. The facility used 14 nursing staff from the agency for approximately 150 shifts during the period in question. During interviews, the Director of Nursing (DON) and the Chief Human Resources Officer (Employee #19) acknowledged the expired license. The DON stated that they were unaware of the expired license, while the Chief Human Resources Officer admitted to not asking about the agency's license until the State Surveyors entered the facility. Despite the nursing staff from the agency having current licenses to practice in D.C., the agency itself was not in compliance with licensing requirements.
Inaccurate Documentation in Medical Records
Penalty
Summary
Facility staff failed to accurately document in the medical records of three residents. For Resident #66, the Treatment Administration Record (TAR) indicated that the central line dressing was changed on specific dates, but an observation revealed that the dressing had not been changed since the initial placement. The Licensed Practical Nurse (LPN) stated that only a Registered Nurse (RN) could change the dressing, and the Director of Nursing (DON) acknowledged that the physician's order was not followed, and the documentation was inaccurate. For Resident #52, the facility staff failed to accurately document the stage of a sacral pressure ulcer on the comprehensive care plan. The resident's medical record showed a Stage 3 sacral decubitus ulcer with specific treatment orders, but the care plan incorrectly documented it as Stage 2. The DON acknowledged the discrepancy and stated that the care plan would be revised. For Resident #72, the facility staff inaccurately documented the resident's December 2023 monthly summary report. The resident had an emergency room visit for a G-tube replacement, which was documented in the nursing progress notes, but the monthly summary report incorrectly stated that there were no ER visits or hospitalizations for that month. The DON acknowledged the inaccurate documentation during an interview.
Infection Control Policy Review Deficiency
Penalty
Summary
Facility staff failed to have documented evidence that 12 out of 25 Infection Control policies and procedures were reviewed at least annually. A review of the facility's Infection Control Policy and Procedure binder revealed that several policies, including those related to MRSA, VRE, infectious waste handling, and outbreak response, lacked review dates. During an interview, the Infection Preventionist acknowledged the absence of review dates and stated that she would work on reviewing the policies to ensure they are based on national standards and the facility's assessment.
Lack of Documented Education on Influenza Vaccination
Penalty
Summary
Facility staff failed to have documented evidence that two residents or their responsible parties received education on Influenza vaccination. Resident #4, who was admitted with multiple diagnoses including Dementia and had a severely impaired cognitive status, received the Influenza vaccine without documented education provided to her or her responsible party. The Preventive Health Care Report and nursing progress notes for Resident #4 indicated that the education sections were left blank, and there was no evidence that the benefits and potential side effects of the vaccine were communicated to the resident or her son, who is her responsible party. Similarly, Resident #49, also admitted with multiple diagnoses including Dementia and a severely impaired cognitive status, received the Influenza vaccine without documented education provided to her or her responsible party. The Preventive Health Care Report and nursing progress notes for Resident #49 showed that the education sections were left blank, and there was no evidence that the benefits and potential side effects of the vaccine were communicated to the resident or her daughter, who is her responsible party. Interviews with facility staff confirmed that the protocol was not followed in these cases.
Failure to Maintain Essential Equipment in Safe Condition
Penalty
Summary
Facility staff failed to maintain essential equipment in safe condition. During a walkthrough of dietary services, it was observed that one food pellet warmer was inoperative. Additionally, two of the four burners on one gas stove did not light up when the knob was activated. These observations were confirmed by a staff member during a face-to-face interview.
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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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