Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ft Washington Rehabilitation And Wellness Center during CMS and state inspections, most recent first.
Late Transmission of MDS Assessments: The facility failed to electronically transmit required MDS assessments within the CMS timeframe for multiple residents. A review found several completed quarterly, annual, discharge return anticipated, and entry MDS assessments were submitted late, and the MDS RN Team Leader and MDS Coordinator LPN verified the backlog and late transmissions during interview.
Missed Quarterly Care Plan Meetings: The facility failed to hold required quarterly care plan meetings for multiple residents. A resident and a family member reported not having regular meetings, and record review showed several residents had gaps between care plan meetings that exceeded the quarterly schedule. For one resident, the quarterly MDS was completed without evidence of an IDT care plan meeting within 7 days or around that time, and the meeting was not held until months later. The SWD and SSD confirmed the meetings were supposed to be quarterly and that several were missed.
A resident reported that staff did not knock before entering the room, and during an interview a GNA abruptly opened the bathroom door from the other side of the room while the resident was speaking with the surveyor. Another GNA stated staff are expected to knock and ask permission before entering a resident’s room, and the DON was notified and acknowledged the concern.
Failure to notify the MD and resident representative occurred when a resident’s eye specialist recommended Latanoprost for blurred vision, but the order was not entered or started and staff did not report the recommendation. In a separate event, an RN crushed non-crushable meds, including EC aspirin, delayed-release ferrous sulfate, levetiracetam, and metformin, mixed them with applesauce, and the resident vomited immediately after ingestion; the MD was told about the vomiting, but not the med error, and the RP was not notified.
A facility failed to maintain a safe and homelike environment for two residents. One resident’s bedside electrical outlet wall plate was broken, leaving the upper socket exposed, and another resident’s smoke detector was hanging from the wall by its wires after being pulled down during fire inspector visits.
Failure to Notify Ombudsman of Hospital Transfers: The facility did not provide written notice to the local ombudsman when two residents were transferred to the hospital for further evaluation of their medical needs. Record review showed no documentation of the required notice, and the Social Services Director and DON confirmed there was no current process in place for sending written notification for hospital transfers, despite the facility policy requiring notice to the State LTC Ombudsman.
A resident’s admission MDS assessment was not completed within the required CMS timeframe. The assessment was initiated but remained in progress when reviewed, and the MDS RN Team Leader and MDS Coordinator LPN confirmed the facility was aware of the late MDS completion and backlog, with corporate mobile MDS nurses assisting.
A resident’s Significant Change MDS was inaccurately coded for oral/dental status. The admission nursing eval documented obvious or likely cavity or broken natural teeth, and survey observation found broken, blackish/greyish teeth, yet the MDS marked Section L0200 as none of the above; the record also showed no evidence of a dental eval while the resident was in the facility.
A resident with bipolar disorder, MDD, and paranoid schizophrenia did not have an updated PASRR that reflected the resident’s mental health diagnoses. The only PASRR in the record was outdated and did not identify mental illness, while later records and a provider attestation documented paranoid schizophrenia and treatment with Depakote. The SWD confirmed the diagnoses were not on the PASRR.
Failure to Care Plan Oxygen Therapy Needs: Two residents with active O2 orders did not have corresponding respiratory care plans in place when reviewed by surveyors. One resident was observed on O2 via NC with an order for continuous O2 at 2 LPM for SOB, yet the record showed no respiratory care plan until after surveyor intervention. Another resident had active O2 orders, including PRN O2 for SOB or hypoxia and orders for tubing and humidifier changes, but the comprehensive care plan did not address oxygen therapy, and the DON confirmed the care plan was missing.
An RN failed to administer medications in the ordered form and did not follow nursing and infection control standards during a medication pass for a resident. The RN handled a tablet with fingers, crushed medications that were not to be crushed, used unsanitized scissors to cut a plastic cup, and mixed the crushed meds with applesauce; another RN later left the med cart unlocked and unattended. The resident complained about the taste and vomited after taking the medication mixture.
A resident who was dependent on staff for ADLs and personal hygiene was observed with contracted hands and fingernails that were long and visibly dirty with dark debris underneath. The care plan and MDS reflected the resident’s need for assistance, but the record did not document any refusal of nail care. A charge nurse confirmed the condition and said she usually cleans and trims the resident’s nails, though refusals were sometimes reported without documentation.
Failure to initiate ordered eye treatment for blurred vision. A resident reported ongoing difficulty seeing clearly even with eyeglasses, and an eye exam documented blurred vision in both eyes with a recommendation for Latanoprost eye drops at bedtime. The order was not entered or started, and an LPN confirmed the physician and RP were not notified after the consult.
Oxygen equipment was not labeled for a resident receiving O2 via NC for SOB. The tubing and humidifier bottle were observed without dates showing when they were put into use or when they should be replaced, and the DON verified the finding. An LPN confirmed staff were expected to date the tubing and humidifier when changed.
A resident’s MRR identified a clinically significant Eliquis and Paxlovid interaction, with a pharmacist recommendation to reduce the Eliquis dose during Paxlovid therapy and for 3 days afterward due to increased bleeding risk. The physician response was blank, and there was no documentation that the recommendation was addressed by the physician, nursing staff, or DON. The MAR showed Eliquis was given as ordered while Paxlovid was administered, and the dose was not reduced as recommended. Facility staff described a process where MRRs were emailed to the DON, ADON, and unit managers, but the recommendation was not followed up on.
A medication pass observation found a 16% error rate, with an RN crushing and mixing four medications in applesauce for a resident, including an EC aspirin tablet ordered as chewable, ferrous sulfate, levetiracetam, and metformin. The resident complained about the taste and vomited immediately after taking the mixture. Staff confirmed there was no do-not-crush list on the med cart, and the DON later provided a pharmacy list identifying those medications as not to be crushed.
The facility failed to provide dental services for two residents. One resident with dementia had a tooth come off and a dental consult was ordered, but the record showed no documentation that the consult was requested or completed despite the order remaining active in the TAR for an extended period. Another resident with Alzheimer's disease was observed with broken, discolored teeth, admission records noted likely cavity or broken natural teeth, and there was no evidence the resident was ever evaluated by a dentist during the stay.
Food service equipment was not maintained in a sanitary manner when the walk-in refrigerator and freezer had broken or missing thermometers, and temperatures were being logged despite the equipment not being properly functioning. On a nursing unit, the nourishment refrigerator contained unlabeled and undated resident food items, including a container of spaghetti and ground meat and a lunch box with multiple food items, and the Unit Mgr could not identify who they belonged to or when they were placed there. The facility policy required resident food to be dated and labeled when brought in and discarded after 72 hours if not used.
Failure to complete therapy screening after fall referral. A resident with mobility difficulties and a history of falls was found on the floor after an unwitnessed fall, and nursing submitted a therapy referral because of the incident. No therapy assessment or evaluation was completed after the referral, and the Therapy Mgr confirmed the screening should have been done.
A facility did not report an allegation of abuse involving a staff member exposing himself to a resident within the required 2-hour timeframe after becoming aware of the incident. The delay in reporting was confirmed through documentation and staff interviews.
A resident did not receive treatment and care in accordance with physician orders and their own stated preferences and goals, as identified by surveyors through observation and record review.
A bed rail was used without first attempting alternative interventions, assessing the resident for safety risk, reviewing risks and benefits with the resident or representative, or obtaining informed consent. The facility also failed to ensure proper installation and maintenance of the bed rail.
A resident experiencing abdominal pain and emesis was assessed by an LPN, who attempted to contact the on-call physician via telehealth but did not receive a timely response. While waiting for a callback, the resident's representative was informed and transported the resident to the ER without a physician's order. The resident was later admitted to the hospital for bowel obstruction and hypotension. The facility administrator acknowledged the on-call provider did not respond in a reasonable timeframe.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to electronically transmit required MDS assessments within the required timeframe for 5 of 12 residents reviewed during the recertification survey. The report states that OBRA-required MDS records must be submitted to CMS's iQIES, and that comprehensive assessments must be transmitted within 14 days of the Care Plan Completion Date while all other MDS assessments must be submitted within 14 days of the MDS Completion Date. A review on 11/19/25 found that Resident #2's quarterly MDS, Resident #9's annual MDS, Resident #16's discharge return anticipated MDS and entry MDS, Resident #18's quarterly MDS, and Resident #21's annual MDS were all completed but transmitted after the required timeframe. The specific records showed that each of the identified assessments had an ARD and completion date, but the transmission dates occurred later than allowed. During an interview on 11/20/25, the MDS RN Team Leader and MDS Coordinator LPN stated that the facility is expected to follow CMS timeframes for completing and submitting MDS assessments, and they verified the late transmissions and assessment backlog. They also stated that corporate mobile MDS nurses were assisting them. The DON was notified of the late transmission of MDS assessments on 11/24/2025.
Missed Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to hold quarterly care plan meetings with the interdisciplinary team for 4 of 9 residents reviewed for care plan meetings during the recertification survey. Care plan meetings are described in the report as meetings with the attending physician, registered nurse, nursing assistant, dietary services, resident, and the resident’s representative if applicable, and they are required to be held quarterly to ensure the plan is continually adjusted to meet changing needs or concerns. For Resident #21, the last three care plan meetings were held on 11/14/24, 4/30/25, and 9/11/25, and the resident reported not having regular care plan meetings. For Resident #13, the last four meetings were held on 5/16/24, 11/15/24, 3/13/25, and 9/11/25, and a family member reported they had not had regular care plan meetings. For Resident #12, the last three care plan meetings occurred on 2/01/24, 10/14/24, and 7/10/2025. For Resident #70, the quarterly MDS assessment was completed on 12/9/24, but there was no evidence of a care plan meeting with the resident and interdisciplinary team within 7 days or around that time; the meeting was not held until 03/06/25. The Social Work Director and Social Services Director confirmed that the meetings were supposed to be quarterly and agreed that the meetings for these residents were missed or not held quarterly.
Failure to Knock Before Entering Resident Room
Penalty
Summary
The facility failed to protect and value a resident’s private space by not ensuring staff knocked before entering the resident’s room. During the survey, Resident #158 stated that staff members do not knock before entering the room. While the surveyor was interviewing the resident, GNA #4 abruptly opened the bathroom door from the other side of the room, and the resident pointed to that event as an example of the concern previously raised. In a later interview, GNA #12 stated that staff are expected to knock and ask permission before entering a resident’s room. The DON was notified of the concern and acknowledged it.
Failure to Notify Physician and Resident Representative of Specialist Recommendation and Medication Errors
Penalty
Summary
The facility failed to notify the physician and the resident representative of a recommendation made after an eye appointment for one resident and of medication errors that occurred during medication administration observation for another resident. One resident reported blurred vision for several months and had been seen by an eye doctor, who documented blurred vision in both eyes and recommended Latanoprost 0.005% one drop in both eyes at bedtime indefinitely with follow-up in 1-2 months. The resident’s record showed no evidence that the Latanoprost order was entered or started, and staff confirmed that the physician and resident representative were not notified of the recommendation. During medication administration observation for another resident, an RN crushed and mixed together aspirin 81 mg enteric coated tablet, ferrous sulfate delayed release 325 mg, levetiracetam 750 mg tablets, and metformin 500 mg tablet in applesauce. The resident stated a preference for powdered medications mixed in applesauce and then complained about the taste and vomited immediately after taking the mixture. The physician was notified of the vomiting and ordered the medications to be re-administered, but the physician was not notified that a medication error had occurred, and the resident representative was not notified of either the medication error or the vomiting episode.
Unsafe Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe and homelike environment for 2 residents out of 28 rooms observed. In Resident #13’s room, the electrical outlet wall plate beside the bed was broken in half, with the upper socket exposed and no wall plate surrounding it; the broken half was missing. In Resident #12’s room, the smoke detector was not secured to the wall and was hanging by its wires coming out of the wall. During later observations with the NHA and Maintenance Director, both conditions were confirmed, and the Maintenance Director stated the smoke detector had been pulled down about two weeks earlier during fire inspector visits and needed replacement.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification to the local ombudsman when residents were transferred to the hospital. This was identified for 2 of 5 residents reviewed for written notice requirements before transfer or discharge, including Resident #15 and Resident #145. Resident #15 was transferred to the hospital for further evaluation of his/her medical needs, and the clinical record contained no documentation that the local ombudsman was notified in writing of the transfer. Resident #145 was also transferred to the hospital for further evaluation of his/her medical needs, and the record likewise showed no documentation of written notification to the local ombudsman. Review of the facility’s Transfer and Discharge Policy showed that the facility is required to send a copy of the written transfer or discharge notice to the Office of the State Long-Term Care Ombudsman. The policy also stated that for emergency transfers, the Social Services Director or designee is required to provide notice to the State Long-Term Care Ombudsman via a monthly list. During interviews, the Social Services Director stated that written notification is not sent to the local ombudsman when a resident is transferred to the hospital, and the DON confirmed that the facility does not have a current process in place to provide written notice of hospital transfers to the local ombudsman. At exit conference, no additional documentation was provided showing that written notification had been completed for either resident.
Late Completion of Admission MDS Assessment
Penalty
Summary
The facility failed to complete an admission comprehensive MDS assessment within the required timeframe for Resident #158. The resident was admitted on [DATE], and an admission assessment was initiated with an ARD of 11/6/25, but the assessment was still in progress at the time of review on 11/24/2025. During interview, the MDS RN Team Leader and MDS Coordinator LPN stated that the facility is expected to follow CMS timeframes for completing and submitting MDS assessments and confirmed the facility was aware of the late completion of MDS assessments and backlog. They also stated that corporate mobile MDS nurses were assisting. The DON was notified of the late completion of MDS assessments on 11/24/2025.
Incorrect MDS Coding of Oral/Dental Status
Penalty
Summary
The facility failed to ensure an accurate MDS assessment for Resident #122 by incorrectly coding the resident’s oral/dental status on a Significant Change MDS. The resident’s admission nursing evaluation form documented “obvious or likely cavity or broken natural teeth” in the oral status section, but the Significant Change MDS completed later coded Section L0200 as “Z. None of the above were present” instead of indicating broken natural teeth. During survey observation, the resident was seen lying in bed with broken teeth that were blackish/greyish in color along with other similarly discolored teeth. Review of the clinical record did not reveal evidence that the resident was ever evaluated by a dentist while residing in the facility. The MDS Team Leader reviewed the record and confirmed that the MDS had been incorrectly coded.
Failure to Complete Updated PASRR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) was completed for one resident with documented mental health diagnoses. Medical record review showed the resident had bipolar disorder, major depressive disorder, and paranoid schizophrenia, but the only PASRR found in the record was completed in 2018 and stated the resident did not have a documented mental illness at that time. No updated PASRR was found that identified the resident’s later diagnoses of paranoid schizophrenia or major depressive disorder. Further record review showed a history and physical completed after the resident’s discharge that documented major depressive disorder and cognitive impairment, and an additional provider attestation form identified paranoid schizophrenia and noted treatment with Depakote. During interviews, the Social Work Director agreed that if the resident was admitted with a mental illness, the diagnosis should have been identified on the PASRR, and later confirmed that the resident’s diagnoses were not on the PASRR. The facility’s Maryland PASRR policy stated that nursing facilities cannot admit or retain an individual with serious mental illness, intellectual disability, developmental disability, or another related condition unless the appropriate state agency has determined nursing facility placement is appropriate.
Failure to Care Plan Oxygen Therapy Needs
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for residents with oxygen therapy orders. For Resident #163, the resident was observed receiving oxygen via nasal cannula connected to a concentrator, and the active physician order confirmed oxygen at 2 LPM via nasal cannula continuously every shift for shortness of breath. A review of the medical record showed no evidence that a respiratory care plan had been initiated for the oxygen use at the time of the surveyor review. The DON stated that care plans were initiated by the nurse upon admission and could be added or updated later by any nurse, and an LPN later provided a respiratory care plan that was initiated only after surveyor intervention. For Resident #145, the comprehensive care plan did not include a care plan addressing oxygen therapy, despite active physician orders for oxygen at 2 liters via nasal cannula as needed for shortness of breath or signs and symptoms of hypoxia, with an additional order to change oxygen tubing and humidifier every 7 days and as needed. The DON confirmed that residents with oxygen therapy orders should have a corresponding care plan and agreed that Resident #145 should have had one. At the time of exit conference, no additional documentation was provided showing that a care plan addressing oxygen therapy had been completed for Resident #145.
Medication Administration Errors and Infection Control Lapses
Penalty
Summary
The nursing facility failed to administer medications in the ordered form and failed to follow professional standards of nursing practice and infection control during medication administration for one resident. During a medication pass, an RN removed a tablet from a bubble pack, placed it in a souffle cup with other medications, then used fingers to pick up the tablet and return it to the bubble pack after realizing it had already been placed in the cup. The RN then crushed multiple medications for the resident, including Aspirin 81 mg enteric coated tablet, Ferrous sulfate delayed release 325 mg tablet, Levetiracetam 750 mg tablet, and Metformin 500 mg tablet, and stated the resident preferred powdered medications mixed in applesauce. After crushing the medications, the RN used unsanitized scissors from the medication cart drawer to cut a plastic cup in half and mixed the crushed medications from two separate plastic pill containers with applesauce. Another RN was observed leaving the medication cart unlocked and unattended while entering the resident's room to administer medications. During administration, the resident complained about the taste and vomited immediately after ingesting the crushed medication mixture. Record review and staff interviews confirmed there was no do-not-crush list on the medication carts, and the DON provided a pharmacy reference showing that Aspirin EC, Ferrous Sulfate, Levetiracetam, and Metformin were not to be crushed.
Dependent Resident’s Fingernails Left Dirty and Untrimmed
Penalty
Summary
The facility failed to ensure that a dependent resident was properly groomed. Resident #18 was observed lying in bed with both hands contracted and bent toward each other, and the fingernails on both hands were approximately 1/2 inch long and visibly dirty with dark substances underneath both thumbs and fingers. The resident’s care plan identified an ADL self-care performance deficit, need for assistance with ADLs, and cognitive deficit, and the MDS indicated the resident was dependent on staff for ADLs including personal hygiene. The clinical record did not contain documentation that the resident refused nail cleaning or trimming. On a later observation, the resident’s fingernails remained uncut and visibly dirty, and the resident stated, “I eat with my hands, and I would like my nails cleaned.” A charge nurse confirmed the condition of the fingernails and stated that she usually trims and cleans the resident’s nails because of the resident’s contractures, but sometimes the resident refuses; however, no refusal documentation was found in the record.
Failure to Initiate Ordered Eye Treatment for Blurred Vision
Penalty
Summary
The facility failed to provide treatment and services to maintain vision for Resident #130. The resident stated that he/she could not see clearly even with eyeglasses on and reported that the problem had been ongoing for several months and was bothersome. The resident also confirmed being seen by an eye doctor in October but was unsure whether the facility was addressing the concern. A review of the resident’s medical record showed an eye care visit with an exam dated 10/13/2025, during which the provider documented blurred vision at all distances in both eyes and recommended Latanoprost 0.005%, 1 drop in both eyes at bedtime indefinitely, with follow-up in 1-2 months. However, the resident’s active and completed physician orders contained no evidence that the Latanoprost medication or treatment had been entered or initiated. An LPN stated that when a resident returned from an appointment, the Charge Nurse or Unit Manager would review the consultation note and notify the attending physician and resident representative if there were recommendations, but confirmed that the physician and resident representative were not notified and the order/treatment was not entered or implemented.
Oxygen Equipment Not Labeled
Penalty
Summary
Failure to provide necessary respiratory care services occurred when Resident #163 was observed receiving oxygen therapy via nasal cannula, but the oxygen tubing and humidifier bottle were not labeled with the date they were put into use or the date they should be replaced. The resident had an active physician order for oxygen at 2 LPM via nasal cannula continuously every shift for shortness of breath. The Director of Nursing verified the observation, and a Licensed Practical Nurse later confirmed that nursing staff were expected to change the tubing weekly, change the humidifier bottle as needed, and date the equipment when it was changed.
Failure to Address Clinically Significant Medication Interaction
Penalty
Summary
The facility failed to act upon a clinically significant medication irregularity identified by the consultant pharmacist for Resident #5. The Medication Regimen Review dated 8/11/25 identified a drug interaction between Eliquis 5 mg twice daily and Paxlovid, and the pharmacist recommended reducing the Eliquis dose by 50% during Paxlovid therapy and continuing the reduced dose for 3 days after the last Paxlovid dose due to increased bleeding risk. The physician response section of the report was blank, and there was no documentation that the recommendation was addressed by the physician, nursing staff, or the DON. Review of the August 2025 MAR showed that Eliquis 5 mg twice daily was administered as ordered throughout the month, while Paxlovid was administered from 8/8/25 through 8/13/25. The Eliquis dose was not reduced during Paxlovid therapy or for 3 days after the last Paxlovid dose as recommended. The facility policy stated that urgent or clinically significant medication irregularities are to be communicated to the medical practitioner and the DON on the day they are identified, and that the DON or designee is responsible for ensuring medication irregularity reports are addressed in a timely manner. During interviews, the DON stated the ADON was responsible for follow-up, while the ADON stated unit managers handled their own units and she only monitored if a unit manager was unavailable. No additional documentation was provided at exit conference showing the recommendation was reviewed, addressed, or implemented.
Medication Crushing Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5% during a medication administration observation, with 4 of 25 medications administered in error for a 16% error rate. During the observation, an RN crushed and mixed in applesauce four medications for a resident: Aspirin 81 mg enteric coated tablet, Ferrous sulfate delayed release 325 mg tablet, Levetiracetam 750 mg tablets, and Metformin 500 mg tablet. The physician’s order indicated that Aspirin was to be given in chewable form, but the RN crushed the enteric coated tablet along with the other medications. The RN stated that the resident preferred medications in powdered form mixed in applesauce. While the RN was administering the crushed medication mixture, the resident complained about the taste and vomited immediately after ingestion. In interviews, an LPN confirmed there was no do-not-crush list on the medication cart and stated Aspirin EC is a do-not-crush medication. Another RN also stated there was no do-not-crush list on the carts, though blister packs may show warnings. The DON later provided a pharmacy list identifying Aspirin EC, Ferrous Sulfate, Levetiracetam tablet, and Metformin as medications not to be crushed, and the facility policy required observing the five rights and determining the most appropriate method for administering oral solid medications when they cannot be given whole.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to provide dental services for 2 residents reviewed for dental care. One resident with dementia and dependence on staff for care had a change in condition when a tooth came off and the nurse documented that the resident was chewing on the tooth. A dental consult was ordered for the resident, and the order remained signed off in the TAR daily for an extended period from November 2023 through May 2025, but the clinical record contained no documentation that a dental consult was requested or completed. The DON stated that consult referrals should be completed within 24 hours and that documentation of the request or completion should be in the medical record, and she confirmed there was no such documentation for this resident. The second resident, admitted with diagnoses including Alzheimer's disease, adult failure to thrive, and cognitive communication deficit, was observed with broken teeth that were blackish/greyish in color and other similarly discolored teeth. Admission documentation noted obvious or likely cavity or broken natural teeth, and an active order listed dental consult as needed, but there was no evidence in the record that the resident was evaluated by a dentist during the stay. The resident could not state whether a dentist had been seen, and the Unit Manager and DON both reviewed the record and confirmed there was no documentation showing a dental visit.
Food Storage and Temperature Monitoring Deficiencies
Penalty
Summary
Food service equipment was not maintained in a manner that ensured sanitary food service operations. During an initial tour of the kitchen with the Certified Dietary Manager, the surveyor observed a temperature log outside the walk-in refrigerator showing 36 degrees Fahrenheit, but the thermometer inside the refrigerator was broken and not functioning. When asked how the temperature had been verified, the CDM stated it could have been recorded before the thermometer broke. The thermometer was replaced, and a later check showed the refrigerator at 39 degrees Fahrenheit. The walk-in freezer also had a temperature log showing -1 degree Fahrenheit, but no thermometer was visible inside. A Dietary Aide found a broken thermometer on the floor of the freezer, and the CDM stated it would be replaced. A later check showed the freezer at 10 degrees Fahrenheit. The CDM confirmed the findings and stated she would educate staff to ensure thermometers in the freezer and refrigerator were visible and working. Proper sanitation for storage of food on the nursing unit was not maintained. During an observation of the nourishment refrigerator on the 1st floor with the Unit Manager, the surveyor found a white plastic container of spaghetti and ground meat with no name or date and labeled only with a room number. The surveyor also found an unlabeled shopping bag containing a lunch box with two containers of rice, a brownie packet, a popcorn packet, and a bottle of water; none of the items were dated or labeled. The Unit Manager stated the refrigerator was used by residents and that food brought in should be labeled with the date received, the resident's name, and room number, and discarded after 72 hours. She did not know who the unlabeled items belonged to or when they had been placed in the refrigerator. The unlabeled and undated items were removed. The facility policy on storage of resident food stated staff will date containers when food or beverages are brought into the facility and discard food when non-safe. The DON stated the items should have been labeled and discarded after 72 hours if not used.
Failure to Complete Therapy Screening After Fall Referral
Penalty
Summary
The facility failed to provide a therapy screening for Resident #17 after an unwitnessed fall and nursing referral to therapy. Record review showed the resident had mobility difficulties and a history of falls, and a change in condition form documented that the resident was found on the floor lying on his/her back after the unwitnessed fall. A Nursing Referral to Therapy form was completed the next day because of the fall, but no therapy assessment or evaluation was completed after the referral. Therapy Manager #17 stated that nurses may use the Therapy Notification Referral when they see a decline or concern, that the goal was to complete screening within 48 hours of a referral, and that the resident should have had a therapy screening after the referral was submitted. She later confirmed that no screening was completed. The Administrator also stated that if a referral was made to therapy, it should have been followed up on.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse immediately, but not later than 2 hours after the allegation was made, as required. Specifically, a male staff member was alleged to have exposed himself to a resident, and the facility became aware of this incident at 8:00 AM. However, documentation showed that the initial report to the State Survey Agency was not sent until 11:21 AM, exceeding the required reporting timeframe. This deficiency was identified during a complaint survey and was confirmed through review of facility documents and staff interviews. The Nursing Home Administrator acknowledged the concern when it was discussed.
Failure to Follow Physician Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Assess and Obtain Consent Prior to Bed Rail Use
Penalty
Summary
The facility failed to try alternative approaches before using a bed rail. When a bed rail was determined to be needed, the facility did not assess the resident for safety risk, did not review the risks and benefits with the resident or their representative, and did not obtain informed consent. Additionally, the facility did not ensure the bed rail was correctly installed and maintained.
Failure to Ensure 24-Hour Physician Availability for Emergency Care
Penalty
Summary
The facility failed to ensure the provision of physician services 24 hours a day in the event of an emergency for one resident. On the evening in question, a resident complained of severe abdominal pain and emesis, and the nurse on duty assessed the resident, determining that the resident was not in distress at that time. The nurse attempted to contact the on-call physician through the telehealth service but did not receive a timely response after calling twice. While waiting for a response, the resident's representative was informed of the situation and ultimately transported the resident to the emergency room without a physician's order, as the nurse was still awaiting a callback from the practitioner. Documentation in the medical record indicated that the resident was later admitted to the hospital for a bowel obstruction and hypotension. Staff interviews confirmed that the nurse took the resident's complaint seriously and followed protocol by attempting to contact the on-call provider, but the lack of timely physician response led to the resident being transported by the representative. The facility administrator acknowledged that the on-call practitioner should have been available and responded in a reasonable timeframe.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Fort Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| George Washington Health & Rehabilitation | 3.8 mi | ★★★★★ | 0 | 0 |
| Mount Vernon Healthcare Center | 4.9 mi | ★★★★★ | 18 | 0 |
| Future Care Pineview | 6.1 mi | ★★★★★ | 14 | 0 |
| Hidden Waters Rehabilitation And Wellness Center | 6.2 mi | ★★★★★ | 30 | 0 |
| Autumn Lake Healthcare At Bradford Oaks | 6.4 mi | ★★★★★ | 8 | 0 |
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