Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hebrew Home Of Greater Washington during CMS and state inspections, most recent first.
Facility staff failed to promptly notify a family member after a hospice-enrolled resident’s death, resulting in a delay of several hours between the documented time the resident was found with no vital signs and the time the family/resident representative was contacted. Review of the Facility Reported Incident and the Resident Change Evaluation (END OF LIFE) showed that the resident was documented as having no pulse, respirations, blood pressure, or temperature in the evening, but the family notification was not recorded until much later that night. The family subsequently reported concern about the late notification, and the DON confirmed the timing discrepancy identified by the surveyor.
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment, including damaged and warped flooring, a wall vent held in place with peeling tape, and stained carpet with food debris in several rooms. On another unit, a resident reported seeing a mouse in their room, where a full trash can, debris on the floor, and chipping along the wall baseboard were observed. In a separate room, a large pile of laundry was found stacked on the floor without an appropriate container for storage.
A resident reported to a surveyor that the call system in their room was not working after pressing the call button and receiving no response. The surveyor observed that pressing the call button did not activate the call light above the door or the call station at the nurses’ station. An LPN confirmed that the system should provide visual hallway lights, an audible alert, and display the room number at the call station when used, but testing showed the call system in that room was not functioning properly.
A resident with intact cognition and no documented behavioral or cognitive impairment was subjected to verbal and non-verbal aggressive behavior by a social worker during an interaction in the social worker’s office. The resident reported that the social worker jumped up, shouted, and screamed, which felt disrespectful, degrading, humiliating, and intimidating; a witness described the exchange as the social worker speaking in a way that could be understood as yelling and chastising the resident. The facility’s investigation concluded the behavior was inappropriate, unprofessional, humiliating, intimidating, and threatening.
Inadequate Supervision During Resident Elopement: A resident with dementia and documented elopement risk left the monitored area after entering an elevator when the WanderGuard system malfunctioned. Staff pursued the resident after the alarm sounded, but the resident exited through a loading dock door and was not located for about 2 hours. The resident later stated the intent was to go to a Verizon store, and the record showed no device was observed in place during the incident.
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required 2-hour timeframe. This deficiency affected 18 residents and involved various allegations, including rape, physical abuse, and injuries of unknown origin. Delays were often due to internal discussions or misunderstandings of reporting requirements, with staff acknowledging the reporting failures.
The facility failed to thoroughly investigate allegations of abuse for nine residents, as investigations often lacked interviews with other residents or staff. In one case, a resident alleged rape, but no other residents from the unit were interviewed. Another resident reported being punched, yet no other residents were interviewed to assess safety concerns. Investigations were further compromised by missing documentation and incomplete interviews, undermining the reliability of the facility's response to these serious allegations.
A facility failed to maintain accurate medical records and document narcotic medication administration for several residents. Errors included incorrect uploading of a hospital transfer summary, missing documentation of narcotic administration, and incomplete medication orders lacking indications for use. These issues were confirmed by the DON and other staff during the survey.
The facility failed to maintain an effective pest control program, as evidenced by numerous reports of mice sightings and droppings in one of the two buildings reviewed. Pest activity logs and resident interviews confirmed persistent pest issues, despite regular visits from a pest control company. The deficiency was discussed with the facility's administration.
The facility failed to ensure proper labeling and dating of food items, maintain a sanitary environment in the nourishment refrigerator, and meet required temperatures for dishwashing machines. Observations revealed unlabeled food, unsanitary conditions, and malfunctioning dishwashers, leading to concerns about food safety and sanitation.
The facility staff failed to timely notify physicians and responsible parties of changes in two residents' conditions. One resident's pressure ulcer assessments and treatment changes were not communicated to the primary physician or responsible party. Another resident's physician was notified an hour after a fall with injury. These communication lapses were confirmed by the DON.
The facility failed to involve a resident with full mental capacity in their care plan meetings and did not document reasons for their absence. Additionally, the care plan for another resident was not updated after a stage 2 sacral pressure ulcer was discovered, despite the requirement to revise care plans following a change in condition.
A facility failed to provide a resident with scheduled showers twice per week, as required by their care plan. The resident, admitted for rehabilitation and strengthening, needed physical help with bathing. The shower log indicated scheduled showers on Mondays and Thursdays, but the GNA Documentation Report for January showed no documentation for these days. The DON confirmed the lack of documentation and stated that GNAs should have recorded if the resident refused or received showers.
A facility failed to provide adequate care for a resident after falls, missing required neuro checks. Another resident experienced delays in assessment and treatment for a fracture, with an X-ray and orthopedic consult delayed. A third resident did not receive a scheduled antibiotic dose due to pharmacy delays. These deficiencies highlight lapses in protocol adherence and timely medical intervention.
Two residents in the facility experienced inadequate pressure ulcer care. One resident did not receive weekly skin assessments for a sacral pressure ulcer, while another resident's worsening pressure ulcers were not properly documented or treated. The facility failed to update wound care orders and conduct necessary evaluations, leading to discrepancies in the residents' medical records.
A resident experienced significant weight loss, dropping from 210 to 192.6 pounds, without timely intervention or documentation of nutritional status. The facility's protocol required action for weight changes over 5%, but the resident's weight loss was not addressed until it reached 8%. The resident was discharged before any confirmation or intervention could be made.
A facility failed to accurately reflect a resident's oral/dental status in the MDS assessments. Despite documentation of a lower denture in the nursing admission assessment and a physician order, the MDS assessments did not indicate any oral or dental concerns. The resident reported broken dentures, which was confirmed by observation. The issue was discussed with the facility's administration.
A facility failed to implement a comprehensive care plan for a resident, leading to delayed incontinence care. The care plan did not address all medical, nursing, and psychosocial needs, and staff interviews revealed that the plan was not updated to reflect the resident's needs. The Director of Nursing acknowledged the oversight, indicating a missed review by the unit manager.
The facility failed to conduct the annual performance review for a GNA, as required. A review of employee records showed no signed evidence of the GNA's performance review and in-service education for 2023 and 2024. The DON confirmed that the 2023 review was missed, and the 2024 review was not signed due to the GNA's PRN schedule. Additionally, no competency assessment was conducted in 2024.
A facility failed to monitor side effects for a resident on Escitalopram Oxalate for depression. The oversight occurred because the order for side effect monitoring was inadvertently dropped from the MAR. Staff interviews confirmed the usual process involves a separate order on the MAR to alert nurses for side effect assessments, which was missing in this case. The DON acknowledged the oversight.
A facility failed to provide adequate dental care for a resident, as evidenced by the lack of follow-up on dental consultations and inaccurate monitoring of the resident's dental status. The resident, who had broken upper and lower dentures and missing teeth, did not receive necessary dental services despite documented orders and referrals. Staff interviews revealed a lack of awareness about the resident's denture status, and the DON acknowledged the absence of follow-up on dental referrals.
Delayed Family Notification Following Resident Death
Penalty
Summary
Facility staff failed to ensure timely notification of a resident’s death to the resident’s family, resulting in a documented delay of approximately two and a half hours between confirmation of death and family notification. A Facility Reported Incident (FRI #2685784) showed that a hospice-enrolled resident was found with no pulse, no respirations, no blood pressure, and no temperature at 7:35 PM on 11/9/2025, as documented on a Resident Change Evaluation (END OF LIFE) form. However, the same document recorded that the family/resident representative was not notified until 10:00 PM that evening. The family member later expressed concern that the resident had passed away around 7:00 PM and that the facility did not notify them until nearly 10:00 PM. During an interview, the DON confirmed the surveyor’s findings regarding the timing documented in the resident’s end-of-life evaluation and the delayed notification to the family.
Failure to Maintain Safe, Clean, and Homelike Resident Rooms
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident rooms as observed during the annual recertification survey. On 2 East [NAME]-Kogod Unit, one room had structural damage to several boards of the center flooring, including soft spots, gaps between planks, edge chipping, warping, and lifting at the seams. In another room on the same unit, a wall vent near the doorway appeared to be held in place by peeling white duct tape-like adhesive. A separate room on this unit had various pink, cream, and brown dry patches of residue bonded with the fibers of the green carpet, along with food particles on the carpet near the bedside table. On the 4 [NAME] Unit, an observation screening identified additional environmental concerns. One resident reported seeing a mouse in their room earlier that morning; upon dual observation with the Clinical Team Manager, the surveyor noted the resident’s trash can was full and had not been emptied, black specs were present on the floor in the corner, and chipping was observed along the wall baseboard area. In another resident’s room, a large pile of clothes was observed on the floor extending approximately midway up the wall, which the resident identified as their laundry, and there was no appropriate container in the room for storing these clothes.
Nonfunctioning Call System in Resident Room
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident’s call system in a specific room bathroom and bathing area was functioning properly. During an initial tour of the 2 East [NAME]-Kogod unit, a resident in the identified room reported to the Surveyor that the call system in his/her room did not work because he/she had pressed the call button and no one came to assist. The Surveyor then observed the resident press the call button, and the call light above the resident’s door did not illuminate, and the call station at the nurses’ station did not activate a call from that room. During an interview with an LPN, the Surveyor was informed that when a resident presses the call button, the system should trigger a visual light outside the resident’s room and another in the hallway by the nurses’ station, an audible alert, and activation of the resident room number at the call station to alert staff that assistance is needed. Upon testing the system, the LPN verified that the call system for this resident’s room was not functioning properly. These observations and interviews demonstrated that the facility did not have a working call system available for this resident’s room as required.
Resident subjected to verbal and mental abuse by social worker
Penalty
Summary
The facility failed to keep a resident free from verbal and mental abuse when a social worker displayed verbal and non-verbal aggressive behavior toward the resident. The resident involved was alert and cognitively intact, with a BIMS score of 15/15, and had no documented diagnoses, medications, or treatment for dementia, impaired cognition, mood, or behavioral disturbances. During the incident, the resident reported that the social worker jumped up, shouted, and screamed, which made the resident feel disrespected and degraded. The resident later described the social worker as having a negative attitude and stated that this behavior was typical. The resident also reported that the social worker’s actions were humiliating and intimidating, and that the resident felt the social worker was going to come across the desk and hit him/her. The resident stated that he/she had not worked with the social worker since the incident. An outside support planner who witnessed the interaction described the social worker as speaking at a passionate level that could be understood as yelling and said the resident was not happy with the tone. The facility investigation documented that the social worker’s behavior was inappropriate, unprofessional, humiliating, intimidating, and threatening toward the resident, and the facility’s own policy defined abuse to include intimidation, humiliation, insults, belittlement, and the use of language that demeans residents. The record review also showed that the incident was not documented in the resident’s progress notes during the period reviewed, although the resident had reported the event to facility leadership and the social worker was removed from the schedule pending investigation.
Inadequate Supervision During Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to a resident who had been identified as having elopement risk and who was using an elopement monitoring device. The resident had a history of dementia noted in the record, with BIMS scores of 15/15 on recent assessments, and was described in social work notes as sometimes confused, restless, wandering, and asking to go home. The record also showed an elopement risk assessment that changed from low risk to moderate risk, along with care plan interventions and TAR entries for a WanderGuard device and related checks. On the day of the event, the resident was observed sitting on the side of the bed eating lunch, with food and drinks within reach and no assistance needed for eating. No WanderGuard was observed in place at that time. The resident stated he/she did not have a WanderGuard device on and said he/she could not leave the building, but could not explain why. Facility leadership later stated that the resident was able to call and enter the elevator because of a glitch in the WanderGuard monitoring system, which allowed the elevator doors to close and access to other floors. According to the facility’s account, the alarm sounded at about 5:00 p.m., staff pursued the resident, and a search of the building was started. Staff followed the resident to the first floor, but the resident had gone to the lower/basement level and exited through a loading dock door. The resident was not found until approximately 6:40 p.m. by a cook from another house, who discovered the resident in a black van. The resident later described the event step-by-step and stated the intent was to go to the Verizon store. The facility investigation and interviews showed that staff did not verify the resident’s self-report, the Missing Person Alert was not activated, and there was no transmitter on the basement door or loading dock door.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and injuries of unknown origin to the Office of Health Care Quality (OHCQ) within the required 2-hour timeframe. This deficiency was identified during an annual and complaint survey, affecting 18 residents out of 60 facility-reported incidents reviewed. The incidents involved various allegations, including rape, physical abuse, and injuries of unknown origin, which were not reported promptly to the regulatory agency as required by regulations. In several cases, the facility staff delayed reporting incidents due to internal discussions or misunderstandings of the reporting requirements. For instance, in one case, a resident alleged rape, and the facility was informed by the resident's daughter, but the report to OHCQ was delayed beyond the 2-hour window. Similarly, other incidents involved residents reporting physical abuse or injuries, but the facility's initial reports to OHCQ were not submitted within the required timeframe, often due to staff waiting to discuss the incidents internally before reporting. The Director of Nursing (DON) and other staff members were interviewed and acknowledged the delays in reporting. In some instances, staff were unaware of the requirement to report within 2 hours if there were no visible injuries, leading to further delays. The facility's failure to adhere to the mandated reporting timeframe for allegations of abuse and neglect highlights a significant deficiency in their reporting processes.
Incomplete Investigations into Abuse Allegations
Penalty
Summary
The facility failed to provide thorough documentation of investigations into allegations of abuse for nine residents during a recertification/complaint survey. In several cases, the investigations lacked interviews with other residents or staff members who could provide additional context or corroborate the allegations. For instance, in the case of a resident who alleged rape, the investigation included interviews with 36 staff members but did not include interviews with other residents from the same unit. Similarly, another resident alleged being punched, but the investigation did not include interviews with other residents on the unit to assess their safety or concerns. In other instances, the investigations were incomplete due to missing interviews with relevant staff or residents. For example, a resident alleged rough treatment during incontinence care, but the investigation only included an interview with the accused GNA and lacked interviews with other residents or staff from the same assignment. Another case involved a resident who reported being slapped by staff, yet the investigation did not include interviews with other residents on the unit who might have witnessed or experienced similar incidents. The facility's investigations were further compromised by missing documentation and incomplete interviews. In one case, a resident alleged sexual assault, but the investigation did not include interviews with other residents on the unit. Additionally, a resident reported a GNA violating their rights, but the investigation lacked interviews with other staff members. These deficiencies highlight a pattern of incomplete investigations, where critical interviews and documentation were missing, undermining the thoroughness and reliability of the facility's response to serious allegations of abuse.
Deficiencies in Medical Record Accuracy and Medication Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards, as evidenced by several deficiencies identified during a recertification/complaint survey. One significant issue involved the incorrect uploading of a hospital transfer summary for one resident into another resident's medical record. This error was confirmed by the Director of Nursing (DON) after an interview with the unit secretary responsible for the upload. Another deficiency was the failure to document the administration of narcotic medications on the Medication Administration Records (MARs) for multiple residents. The review revealed that a staff member signed out narcotic medications for several residents, but these administrations were not documented in the MARs. Interviews with the DON confirmed that the staff member failed to accurately document the administration of these medications, and some residents could not recall the number of doses received. Additionally, the survey identified incomplete medical orders for a resident, where the orders for Seroquel and Amlodipine did not include an indication for use. Despite prior recommendations from a pharmacist to include diagnoses or indications for use in medical orders, these were not reflected in the orders. The Clinical Team Manager and the DON confirmed the absence of indications in the orders, acknowledging the oversight in ensuring that the indication for use was displayed in the medical orders.
Facility Fails to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by numerous reports of mice sightings and droppings in one of the two buildings reviewed during the recertification/complaint survey. The pest activity logs from September 2024 to February 2025 revealed frequent entries of mouse sightings and droppings in various patient care areas, including resident rooms, dining rooms, and common areas. Despite the facility's pest control company visiting three times a week, the logs indicated persistent pest activity, with multiple entries each month documenting the presence of mice. Interviews conducted with residents and staff corroborated the findings in the pest activity logs. Several residents reported seeing mice in their rooms and common areas, with some residents experiencing daily sightings. A geriatric nursing assistant also confirmed seeing a mouse in the resident hallway and reported it to the housekeeping staff. These interviews highlighted the ongoing issue of mice presence within the facility, affecting the residents' living conditions. The findings were discussed with the facility's Vice President of Building Services and the Administrator, who acknowledged the pest control logs and resident reports. The surveyor's investigation and interviews confirmed the facility's failure to effectively address the pest control issue, leading to a deficiency in maintaining a safe and sanitary environment for the residents.
Deficiencies in Food Safety and Dishwashing Practices
Penalty
Summary
The facility failed to ensure proper labeling, dating, and expiration of nourishment items in one of its kitchens. During an initial tour, a surveyor observed a reach-in refrigerator containing various food items such as orange slices, cold salad sandwiches, and containers of fruit and cottage cheese without any labeling or dates to indicate preparation or expiration. A tray of cheese sandwiches was also found with an expired label, leading to its disposal by the Certified Dietary Manager (CDM). The CDM acknowledged the issue but was unable to confirm when the foods had been prepared or were to expire. Additionally, the facility did not maintain a sanitary environment in the nourishment refrigerator. The surveyor found a cardboard box with condiment packets and tea bags showing visible spots of black, brown, and green matter. A container of soymilk was also found with an expired label. The Project Manager, overseeing the kitchen temporarily, confirmed the unsanitary conditions and disposed of the items. The Senior Dining Director and CDM were made aware of these concerns and acknowledged the issues. The facility's dishwashing machines also failed to meet the required manufacturer temperatures for sanitization. Observations revealed that the dishwashing machines in both the main and additional kitchens were not reaching the necessary temperatures for wash and final rinse cycles. Maintenance staff identified issues with the machines, such as a malfunctioning sensor and blown fuses, which prevented the machines from sustaining the required temperatures. Despite attempts to address these issues, the machines continued to operate below the recommended temperatures, leading to concerns about their effectiveness in sanitizing dishware.
Failure to Timely Notify Physicians and Responsible Parties
Penalty
Summary
The facility staff failed to notify a resident's physician and responsible party for changes in the resident's condition in a timely manner. For Resident #630, the staff did not inform the primary physician about the assessments of a sacral pressure ulcer when the wound care doctor was unavailable. Additionally, there was no documentation indicating that the resident's responsible party was notified of changes in wound care orders, despite multiple changes occurring over several months. This lack of communication was confirmed by the Director of Nursing during an interview. In another instance, the facility staff delayed notifying Resident #643's physician after the resident experienced a fall with injury. The fall occurred at 5:45 PM, but the physician was not informed until an hour later. The resident sustained an injury to the right elbow and hit their head, necessitating a hospital transfer for further assessment and treatment. The Director of Nursing confirmed the delay in notification during an interview.
Failure to Involve Resident in Care Plan Meetings and Update Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to involve a resident with the capacity to attend their own care plan meetings and did not document the reasons for their absence. Resident #96, who had a perfect BIMS score indicating full mental capacity, reported never being informed about care plan meetings. The Director of Social Work claimed the resident often declined to attend due to personal issues, but there was no documentation to support this claim. Upon review, it was confirmed that there was no record of the resident being invited or the reasons for their non-attendance. Additionally, the facility did not update the care plan for Resident #963 after a significant change in condition. Initially, the resident's skin was noted as normal upon admission, but a stage 2 sacral pressure ulcer was discovered five days later. Despite this change, the care plan was not revised to address the new condition. The Director of Nursing confirmed that the care plan had not been updated following the discovery of the pressure ulcer, which was a requirement when there is a change in a resident's condition.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident who required assistance received showers twice per week, as was the established care plan. This deficiency was identified during a recertification/complaint survey for a resident admitted in December 2022 from an acute care hospital for rehabilitation and strengthening. The resident's medical record indicated a need for physical help with bathing, and the shower log specified that showers were to be provided on Mondays and Thursdays. However, the GNA Documentation Report for January 2023 showed blank spaces for all scheduled shower days, indicating that the showers were not documented as given. During an interview, the Director of Nursing confirmed the lack of documentation and stated that GNAs should have recorded whether the resident refused or received showers.
Deficiencies in Resident Care and Treatment
Penalty
Summary
The facility failed to provide adequate care for Resident #614 following two falls on the same day. After the first fall, the staff did not complete the required neuro checks according to the facility's 72-hour assessment protocol, missing checks at 4:15 PM and 5:15 PM. After the second fall, the staff failed to restart the neuro check protocol, missing several checks that were supposed to occur every 15 minutes and hourly thereafter. This lack of adherence to protocol was confirmed by the Director of Nursing. Resident #131 experienced a delay in receiving appropriate medical assessment and treatment for a left arm fracture. Despite the resident's daughter requesting an assessment for soreness, the initial assessment was not thorough, focusing only on the hand. An X-ray was not ordered until several days later, after the resident exhibited significant pain. The Occupational Therapy evaluation was also delayed, occurring five days after the order was given, and the resident did not receive an orthopedic consult until being sent to the ER, where the fracture was confirmed. Resident #913 did not receive a scheduled dose of Daptomycin for endocarditis due to a delay in medication delivery from the pharmacy. The resident was admitted to the facility with orders to continue antibiotic therapy, but the medication was not administered until two days later. Despite multiple calls to the pharmacy, the medication was not delivered on time, resulting in a delay in treatment. The Director of Nursing and Clinical Team Manager acknowledged the delay in administering the medication.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility staff failed to provide adequate treatment and services to prevent and heal pressure ulcers for two residents. Resident #630 was assessed to have a Stage II sacral pressure ulcer, but the facility staff did not conduct weekly skin assessments, including measurements, on several occasions. Specifically, there were no assessments from 6/26/23 to 7/13/23, a gap of 17 days. The Director of Nursing confirmed the failure to perform these assessments during an interview. Resident #660 was admitted with a Stage II pressure ulcer on the right buttock, and the condition of the resident's wounds worsened over time. The facility's documentation showed discrepancies in the wound's status, and there were no additional orders or evaluations despite the worsening condition. The wound consultant's notes were not updated weekly, and there was a lack of follow-up assessments and order changes when the resident's wounds deteriorated. The Director of Nursing confirmed the absence of additional documentation to support evaluations during the worsening of the resident's condition.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to address appropriate care for a resident experiencing significant weight loss. The deficiency was identified during a recertification survey, where it was found that a resident had lost a substantial amount of weight over a short period. The resident's initial weight was recorded at 210 pounds, and over the course of several weeks, the weight decreased to 192.6 pounds, marking an 8% loss from the initial weight. Despite this significant weight loss, there was no documentation of any follow-up nutrition assessment or intervention after the initial assessment upon admission. Interviews with facility staff revealed a lack of timely response to the resident's weight changes. The clinical nutrition manager stated that weight changes were only addressed if they exceeded a 5% difference, and the resident's weight loss was not acted upon until it reached 8%. The Director of Nursing confirmed that nursing staff were expected to re-check weights with more than a 5-pound difference and notify providers, but this protocol was not followed. The resident was discharged before any confirmation or intervention could be made regarding the weight loss, and there was no documentation of the resident's nutritional status or any actions taken to address the weight loss trend.
Inaccurate MDS Assessment of Oral/Dental Status
Penalty
Summary
The facility failed to ensure that the Comprehensive Minimum Data Set (MDS) assessments accurately reflected a resident's oral and dental status. This deficiency was identified during a recertification/complaint survey for one of the four residents reviewed. The resident in question was initially admitted to the facility after abdominal surgery and was readmitted following a hospitalization for high ostomy output. Despite the presence of a lower denture being documented in the nursing admission assessment and a physician order, the MDS assessments conducted on two separate occasions did not reflect any oral or dental concerns. The MDS manager, responsible for conducting the assessments, acknowledged the oversight. She confirmed that the assessments included a record review, resident interview, and physical assessment, yet failed to code any oral or dental issues in the relevant section of the MDS. The resident, during an interview, reported having broken upper and lower dentures, which was corroborated by a surveyor's observation. The discrepancy between the documented presence of dentures and the MDS coding was discussed with the facility's Administrator and Director of Nursing during the exit conference.
Failure to Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, as identified during a recertification/complaint survey. The deficiency was evident for one resident whose care plan did not address all medical, nursing, and psychosocial needs identified in the admission comprehensive assessment. Specifically, the resident experienced an episode of incontinence, and the care was delayed for several hours despite staff being notified. The Geriatric Nursing Assistant (GNA) task list showed incontinence care was documented only once on the day of the incident. Interviews with staff revealed that the care plan was not updated to reflect the resident's needs. RN #55 confirmed that the care plan needed updating and that all nurses could update it as needed. The unit manager, RN #70, stated that care plans should be updated initially within 30 days, as needed with any change, and every 90 days with the admission assessment. However, the care plan for the resident did not reflect personal care needs or active diagnoses and interventions. The Director of Nursing acknowledged the oversight, indicating that the unit manager was responsible for the care plan review, which was missed.
Failure to Conduct Annual Performance Review for GNA
Penalty
Summary
The facility failed to conduct the required annual performance review for a Geriatric Nursing Assistant (GNA), identified as GNA #71, during the recertification/complaint survey process. The surveyor's review of three GNA employee records revealed that there was no signed documented evidence of GNA #71's performance review and in-service education for the years 2023 and 2024. During a telephone interview, the Director of Nursing (DON) acknowledged that the performance review and competency assessment for GNA #71 were missed in 2023. Although the 2024 performance review was documented, it was not signed due to GNA #71's PRN (as needed) work schedule. Furthermore, the DON confirmed that no competency assessment was conducted in 2024, as it is typically done alongside the performance review.
Failure to Monitor Side Effects of Psychotropic Medication
Penalty
Summary
The facility failed to ensure proper monitoring for side effects of a psychotropic medication for a resident, which was identified during a recertification/complaint survey. The resident was receiving Escitalopram Oxalate for depression, starting from early January. However, the medical record review revealed that side effect monitoring was not instituted for this medication, which is a necessary step in managing psychotropic medications. Interviews with facility staff, including an LPN and the Clinical Team Manager, confirmed that the usual process for monitoring side effects involves a separate order on the medication administration record (MAR). This order alerts nurses to complete and document assessments for side effects. It was discovered that the order for side effect monitoring was inadvertently dropped from the MAR in late December, leading to the oversight. The Director of Nursing acknowledged the oversight, confirming that the medications had been reviewed but the monitoring order was missed.
Failure to Provide Adequate Dental Care
Penalty
Summary
The facility failed to provide appropriate dental care for Resident #269, as evidenced by the lack of accurate monitoring of the resident's dental status and failure to follow up on dental services. The resident was admitted to the facility in February 2024 and readmitted in mid-April 2024 after hospitalization. The nursing admission assessment documented the presence of partial lower dentures, but subsequent oral health assessments indicated significant dental issues, including decayed or broken teeth. Despite a physician's order for assistance with the resident's partial lower denture, there was no follow-up documentation for dental consultations requested in August and October 2024. Interviews and medical record reviews revealed that the resident's dental needs were not adequately addressed. The resident reported having broken upper and lower dentures and missing teeth, which was confirmed by the surveyor. Staff interviews indicated a lack of awareness regarding the resident's denture status, and the social worker confirmed that the resident's insurance did not cover new dentures. The Director of Nursing acknowledged the absence of follow-up on the dental referral, highlighting a deficiency in the facility's dental care provision.
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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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Nursing homes near Rockville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tuckerman Rehabilitation And Healthcare Center | 1.7 mi | ★★★★★ | 5 | 0 |
| Montcare At Bethesda | 2.1 mi | ★★★★★ | 14 | 0 |
| Sterling Care Bethesda | 2.1 mi | ★★★★★ | 24 | 0 |
| Potomac Valley Rehabilitation And Healthcare | 2.5 mi | ★★★★★ | 3 | 0 |
| Complete Care At Wheaton | 2.5 mi | ★★★★★ | 0 | 0 |
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