rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-03-28,675,D,1,0,192W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff and resident interviews and record review for three (3) discharged residents, it was determined that facility staff failed to ensure that the Resident #1's medication was available to administer. The findings include: Resident #1 was admitted to the facility on (MONTH) 19, 2019. According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 1, 2019, Resident #1 scored 15/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14, a score of 13-15 suggests that the resident is cognitively intact. Resident #1 was assessed as requiring supervision for eating, and extensive assistance for bed mobility, transfers, toilet use, and personal hygiene in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. A review of the (MONTH) and (MONTH) 2019 Medication Administration Records (MARs) revealed the following: All of the following physician's orders [REDACTED]. Aspirin 81 mg daily - resident unavailable 1/21/2019 at 11:26 AM physician's orders [REDACTED]. Eliquis 5 mg twice a day - 1/21/2019 resident unavailable at 11:26 AM physician's orders [REDACTED]. [MEDICATION NAME] 20 mg daily - 1/21/2019 resident unavailable at 11:26 AM physician's orders [REDACTED]. [MEDICATION NAME] 40 mg daily - 1/21/2019 resident unavailable at 11:26 AM physician's orders [REDACTED]. Humalog 35 units TID - 1/21/2019 -resident unavailable at 11:26 AM physician's orders [REDACTED]. [MEDICATION NAME] 100 mg TID - resident unavailable 1/21/2019 at 11:26 AM physician's orders [REDACTED]. There was no evidence in the resident's record that showed further attempts to administer the above listed medications. There was no explanation in the nurses' notes or the MARs as to why the resident was unavailable or why further attempts were not made to administer the medication. [MEDICATION NAME] 20mg every 8 hours - 7 AM and 8 pm drug unavailable 1/20/19 physician's orders [REDACTED]. [MEDICATION NAME] 200 mg - resident unavailable 1/21/2019 physician's orders [REDACTED]. Sevelamer [MEDICATION NAME] - TID- 1/20/2019 - drug not available physician's orders [REDACTED]. There was no evidence in the resident's record of any attempts to secure the above three (3) listed medication. There was no explanation in the nurses' notes or the MARs as to why there medications were not available. A telephone interview was conducted with Employee #1 on (MONTH) 5, 2019 at 2:30 PM. He/she acknowledged the above information and confirmed that the missing medications were available in the stock cart. The records were reviewed (MONTH) 21, 2019.",2020-09-01
2,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-11,600,G,1,0,4UMZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review for one (1) of seven (7) residents reviewed, it was determined that facility staff failed to stop giving morning care to a combative resident who was attempting to scratch the employee. Subsequently, the resident sustained [REDACTED]. Resident #1 The findings include: Resident #1 was admitted to the facility on (MONTH) 29, (YEAR). According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 3, 2019, he/she was assessed with [REDACTED]. He/she was assessed as requiring extensive assistance of one (1) for bed mobility, transfers, dressing, personal hygiene and totally dependent for bathing and toilet use with the assistance of two (2) in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse's note dated (MONTH) 16, 2019 at 12:30 PM: Writer was called by CNA to come to resident room, when asked CNA said He/she was trying to give care to resident when he/she became combative and in the process of turning, resident hit his/her head on the side rail of the bed. Happened at 11:35 am. Writer went and assessed resident and noted a swelling on his/her left face. Supervisors were informed. NP was called , who gave orders for resident to be transported via EMR/911. To the nearest ER. Resident #1 is alert and unable to explain what happened. His/her [DIAGNOSES REDACTED]. On assessment resident noted with swelling of the left fore head near the left eye with a cut on the left upper lip with minimal bleeding which was cleansed with normal saline. Ice pack applied to the left forehead swelling. V/S laying 138/69, P74, T 97.7, Spo2 98% on room air. V/S sitting B/P 157/80, P77, T98.2, R 18. Pulse ox room air 97% . Finger stick 142 mg/dl. Tylenol 2 tabs 325 mg was administered for pain 4/10 and was very effective. Neuro check initiated. RP made aware. According to a progress note written by the dentist on (MONTH) 21, 2019: Received a call on 6/19 regarding patient injury. Informed charge nurse that [MEDICATION NAME] would be added prior to procedure. He/she told me he/she would call me once it was received (after NP left orders and X-ray results). S/P hit face on bed railing. Patient has black eye (periorbital) swollen lip (upper/inner) and slightly bruised periocular area. Patient is .lying in bed/sleep. Comprehensive exam of oral soft/hard tissues completed to rule out fractured teeth. Patient has fractured [MEDICATION NAME] teeth unrelated to this incident. There is no associated mobility or intra-oral trauma. Patient does have swelling of face and lips which are clearly trauma related. Patient's teeth which are broken also have excessive decay which is unrelated to incident. Recommend that area of trauma be resolved prior to any future clinical treatment unless patient's teeth become symptomatic due to patient's altered mental status. Dr. contacted (RP) to inform him/her of findings. A telephone interview was conducted with Employee #1 on (MONTH) 8, 2019 at 9:40 AM. He/she was giving care to Resident #1 when the incident occurred. Employee #1 stated, I was cleaning him/her up and I had his/her diaper and pants to pull up. Then I was done with the job. He/she started to wave around his/her arms and tried to scratch me. I turned him/her to pull up his/her pants and his/her arms went under him/her. Then he/she hit her face on the side rail. It's metal. I called the charge nurse who called the supervisor and then they did an assessment and we sent him/her out 911. Employee #1was asked if he/she stopped caring for Resident #1 when he/she became combative. Employee ##1 stated, I left him/her alone. I went to the bathroom and cleaned up the items I used. I went back to the resident. He/she was still combative . I know that I was supposed to wait a few minutes to let him/her calm down, but I had to get the job done. I had to finish pulling up his/her pants because I had to finish the job. Facility staff continued to complete morning care despite the resident being combative and attempting to scratch Employee #1. Subsequently, the resident sustained [REDACTED]. A face-to-face interview was conducted with Employee #2 on (MONTH) 1, 2019 at 10:45 AM, who acknowledged the above findings. The record was reviewed (MONTH) 1, 2019.",2020-09-01
3,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-07-20,660,D,1,0,2ROW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, for one (1) of three (3) residents, it was determined that facility staff failed to ensure a safe discharge for Resident #1. The findings include: Resident #1 was admitted to the facility on (MONTH) 3, (YEAR). According to the admission Minimum Data Set (MDS) assessment with a target date of (MONTH) 18, (YEAR), Resident #1 scored 15/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14, a score of 13-15 suggests that the resident is cognitively intact. Resident #1 was assessed as requiring extensive assistance with bed mobility, transfers, dressing, and personal hygiene and totally dependent for toilet use and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. On (MONTH) 13, (YEAR), Resident #1 received a notice of Medicare non-coverage effective (MONTH) 15, (YEAR). Employee #1 petitioned the (Medicare management company) for a discharge on (MONTH) 18, (YEAR), to allow the facility to arrange for a safe discharge with appropriate home care. The (Medicare management company) agreed to a discharge date of (MONTH) 18, (YEAR). Employee #1 explained the situation to Resident #1 on (MONTH) 14, (YEAR). According to Employee #1's progress note dated (MONTH) 14, (YEAR): .met with resident and responsible party. Advised resident and family members of Medicare non-coverage and right to appeal the decision through independent medical review. Resident declined appeal .Resident advised and agrees to discharge on 6/18/18 . According to Employee #1's progress note dated (MONTH) 18, (YEAR): Resident is discharged to the care of his/her family. Discharge planning conference held on this date with all disciplines present. (Medicare Management Company) contacted for case management. . Referral was sent to Delmarva by Employee #1 on (MONTH) 14, (YEAR) requesting evaluation for home care services. Delmarva and the (Medicare management company) approved Resident #1 for home care. Resident #1 had previously been discharged from the facility on (MONTH) 10, (YEAR) and all necessary durable medical equipment was in place. A telephone interview was conducted with the (Medicare management company) on (MONTH) 23, (YEAR) at 10:15 AM. The Medical review supervisor stated that Employee #1 (at the nursing facility) was notified on (MONTH) 20, (YEAR) that Resident #1 had been approved for home care services and a referral from the facility physician was all that the (Medicare management company) needed to initiate home care services. There was no evidence that Employee #1 had followed-up with the home care services agency. On (MONTH) 20, (YEAR), two (2) days after the discharge, the complainant contacted Employee #1 to notify him/her that homecare services had not yet started. The complainant requested information to be sent to two (2) other home care agencies. Information was faxed to the additional one (1) of the home care agencies by Employee #1 the same day. There was no working fax for the other home care agency. There was no evidence that Employee #1 had followed-up with the home care services agency. Through interview conducted on (MONTH) 27, (YEAR) at 10:30 AM, Employee #1 acknowledged that he/she failed to follow up with Delmarva and (Medicare Management Company) to ensure that home care services were scheduled for Resident #1. Employee #1 stated in an interview conducted on (MONTH) 27, (YEAR) at 10:30 AM that he/she thought since services had previously been received in the home, and that this was a simple resumption of care not requiring a referral. Employee #1 acknowledged that he/she failed to follow up with Delmarva and the (Medicare management company) regarding the home care agencies chosen by the family to ensure that Resident #1 received home care services. The record was reviewed (MONTH) 18, (YEAR).",2020-09-01
4,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,584,E,0,1,BMNI11,"Based on observations and interview, the facility failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by soiled bathroom vents in four (4) of 65 residents' rooms and ten (10) of ten (10) containers of Boost nutritional drinks that were stored for use beyond their expiration date. Findings included . During an environmental tour of the facility on (MONTH) 18, 2019 between 10:00 AM and 3:30 PM the following observations were made: 1. Bathroom vents in Resident rooms' #159, #160, #208 and #237 were soiled with dust, four (4) of 65 resident's rooms. 2. Ten (10) of ten (10) eight-ounce carton containers of Boost nutritional supplement drinks, stored in the pantry on Unit 2 Blue, were expired as of (MONTH) 30, 2019. Employee #9 acknowledged the above findings during a face-to-face interview on (MONTH) 18, 2019 at approximately 3:00 PM.",2020-09-01
5,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,610,L,1,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to: thoroughly investigate an incident of abuse and/or neglect for Resident #164, implement measures to prevent potential abuse and/or neglect to other residents within the facility; and take appropriate corrective actions to keep other residents safe from possible abuse and/or neglect in one (1) of 56 sampled residents. The census on the first day of survey was 243. Findings included . On (MONTH) 23, 2019, at 11:09 AM an Immediate Jeopardy (IJ)-L was identified at 42 CFR 483.12 (c)(2)-(4), F610. On (MONTH) 25, 2019 at 3:13 PM, the facility's Administrator provided a letter to the State Agency Survey team documenting the corrective action plan, as follows: The CNA identified in the complaint survey is no longer employed as of 7/16/2019. All residents were checked and three residents who are combative and/or exhibit combative behaviors were identified. Additional training was provided on the spot for those staff members on 7/22/2019. A meeting was conducted with the Administrator and the DON (Director of Nursing) on 7/23/2019 and 7/24/2019. Root cause analysis and investigation principles as it pertains to Abuse were addressed. All components of abuse were discussed including the interpretation of willful and its relationship to abuse. Abuse training and care of combative resident (training) was started on 7/21/2019 for all staff and is currently in progress. The managers will monitor the care of residents who are combative using the behavioral monitoring tool (see audit tools). The nurse managers and supervisors will continue to monitor the staff that provide care to residents who exhibit combative behaviors. Interventions will be implemented as indicated. The information will be provided to the DON who will provide this information to the QAPI committee quarterly and/or more frequently as indicated. Family request female: The Unit Manager received individual counseling and training on 7/23/2019. Unable to retrospectively correct the occurrence. All Unit Managers received training on 7/23/2019 and 7/24/2019 as it pertains to resident's rights, specifically their wish as it pertains to the caregiver. All Units were checked on 7/23/2019, via the nursing management team to determine if other residents had preference as it pertains to the sexuality of the caregiver. One resident was identified on 7/23/2019 and the Unit manager ensured that it was incorporated in the care plan on 7/23/2019. The Interdisciplinary team was re-educated on care planning and updating the care plan as the resident's conditions changes following detailed assessment of the resident on 7/23/2019. Upon admission and care plan meeting/conferences, the managers will determine the needs of the residents, specifically if a resident request a female and/or male care giver. The resident who expresses the female/male will be checked to ensure that this request was honored. This will be done via the assignment sheet every shift and reported to the QAPI (Quality Assurance and Performance Improvement) committee quarterly and/or more frequently as indicated. The nursing management audits the care plan monthly (see audit tool). When a care plan has not been updated the appropriate discipline is notified. This information is provided to the DON who presents this information to the QAPI committee quarterly and/or more frequently as necessary. In-service/Training: Training of the Administrator and DON regarding Root Cause Analysis and Investigation Principles as it pertains to Abuse (training completed on (MONTH) 24, 2019) Training of the Clinical Leadership Team (Training completed (MONTH) 19, 2019) Evidence of Abuse Training (Training for leadership, managers, and staff on abuse, residents with combative behaviors done on (MONTH) 19 2019- (MONTH) 24, 2019) Training on assignment of male/female CNA per resident's wishes (Training completed (MONTH) 24, 2019) The IJ was abated after the team verified that the plan of correction was in place on (MONTH) 25, 2019, at 4:07 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to an F. Policy Title: Prohibition of Abuse; ADM01-003; Revised (MONTH) 2019 stipulates, [NAME] Stoddard Baptist Global Care, Inc. promotes the residents rights to be free from abuse, neglect, misappropriation of resident property and exploitation .No abuse or harm of any type will be tolerated and residents and staff will be monitored for protection . Prevention: 4. The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of resident with needs and behaviors which might lead to conflict or neglect. Identification: .Because some cases of abuse are not directly observed, understanding resident outcomes of abuse could assist in identifying whether abuse is occurring or has occurred. Possible indicators include, but are not limited to: 1) an injury that is suspicious because the source of the injury is not observed or the extent or location of the injury is unusual, or because of the number of injuries either at a single point in time or over time. Investigation: 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witness, and others who might have knowledge of the allegations; 6. Providing complete and thorough documentation of the investigation. Protection: 1. In the interim of the investigation process, the alleged abuser may be suspended from work until an official notice is issued for clearance to return to work or otherwise by Human Resources. 6. Protection from retaliation. Reporting: .The results of all investigations are reported to the administrator or his or designated representative .and if the alleged violation is verified appropriate correction action must be taken. .2. Resident abuse is a ground for immediate termination refer to Employee Handbook. Employee Handbook revised (MONTH) (YEAR), page 5, stipulates, Abuse Prohibition policy: Actions of such may result in immediate termination . Record Review Review of Resident #164's medial record showed she was admitted to the facility on (MONTH) 29, (YEAR). The Quarterly Minimum Data Set (MDS) dated (MONTH) 3, 2019, under Section A1000 (Race/Ethnicity) the resident was coded as Asian, Native Hawaiian or other Pacific Islander. Under Section A1100 (Language) the resident was coded as needing and wanting an interpreter to communicate with a doctor or health care staff and preferred language Chinese. She was assessed with [REDACTED]. She was assessed as requiring extensive assistance of two (2) persons for bed mobility, transfers, dressing, toileting, personal hygiene and totally dependent for bathing under Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Further review of the record showed a nurse's note dated (MONTH) 16, 2019, at 12:30 PM: Writer was called by CNA (Certified Nursing Assistant/Employee #4) to come to resident room, when asked CNA said, He was trying to give care to resident when she became combative and in the process of turning, resident hit her head on the side rail of the bed. Happened at 11:35 am. Writer went and assessed resident and noted a swelling on her left face. Supervisors were informed. (Nurse Practitioner- Name) was called, who gave orders for resident to be transported via EMR (emergency response)/911. To the nearest ER (emergency room ). (Resident #164) is alert and unable to explain what happened. Her [DIAGNOSES REDACTED]. On assessment resident noted with swelling of the left fore head near the left eye with a cut on the left upper lip with minimal bleeding which was cleansed with normal saline. Ice pack applied to the left forehead swelling. V/S (vital signs) laying 138/69, P (pulse) 74, T (temperature) 97.7, Sp02 (peripheral capillary oxygen saturation) 98% on room air. V/S (vital signs) sitting B/P (blood pressure) 157/80, P 77, T (temperature) 98.2, R (respirations) 18. Pulse ox (oximetry) room air 97% FS (finger stick) 142 mg/dl (milligrams per deciliter). Tylenol 2 tabs 325 mg (milligrams) was administered for pain 4/10 and was very effective. Neuro (neurological) check initiated. RP (Responsible Party) made aware. Continued review of the record showed the (Hospital Name), computed tomography report dated (MONTH) 16, 2019, showed Resident #164 sustained trauma, Left periorbital soft tissue swelling. Associated displaced fracture lamina papyracea (orbital fracture). Minimal blood in the left ethmoid sinuses. Resident #164 was discharged from the facility on (MONTH) 26, 2019. Review of Employee #4's Personnel Record Review of Employee #4's statement dated (MONTH) 20, 2019 showed, Incident report on the 16th of June. I went into (Resident #164) room to clean her up, in the process of cleaning her, she became combative and hit her face on the bedrail which caused swelling on her face. So I decided to report the situation to the charge nurse immediately. I was not contacted on this during the week. Review of Employee #4's time card showed he arrived at work on (MONTH) 16, 2019 at 9:29 AM, punched out at 1:30 PM punched back in at 2:00 PM and punched out for the shift at 3:48 PM. The Personnel Report of Change dated (MONTH) 21, 2019 showed, the Employee #4 was suspended for three (3) days (6/21/19, 6/22/19, and 6/23/19). In-service records showed Employee #4 attended in-services on Prohibition of Resident Abuse and Neglect, Managing Resident with Dementia and Aggressive Behavior, Cultural Competency, and Resident Safety during ADL (activities of daily living) care on (MONTH) 25, 2019, (five days after the incident). The Personnel Report of Change dated (MONTH) 16, 2019 showed, the Employee #4 was terminated from the facility on (MONTH) 16, 2019. There was no evidence facility staff failed to immediately remove Employee #4 from the facility after the incident to ensure the safety of all residents, as evidence below: The incident occurred at approximately 11:35 AM on (MONTH) 16, 2019. According to the Employee's time card, he worked the duration of the shift (until 3:48 PM). There was no documentation of Employee #4's suspension until (MONTH) 21, 2019 (five days after the incident occurred. (The Employee did not work during this period.) On (MONTH) 27, 2019, Employee #4 was allowed to return to work, and assume his duties as a CN[NAME] Interviews: During a face-to-face interview with the Unit Manager (assigned to the unit of Resident #164) on (MONTH) 19, 2019, at 2:13 PM, she stated, I was the manager at the time of the incident with the CNA, it was a weekend on Sunday the supervisor called me there was an incident that occurred on your floor and we called 911. The CNA take took care of her an abrasion during care, the face is swollen and we put on ice packs we have to send her out 911. I do not know why Employee #4 was taking care of her because the family requested that they did not have a male they told this to me. The family requested to have another (Employee Name) and that weekend she was off. Employee # 4 knew he was not supposed to take care of the resident. Employee #4 came in late and the other CNA switched (the resident assignment) .the charge nurse did not know that he switched the resident (assignment). She (the resident) is always is agitated . The surveyor asked, What do you do when a family make a request regarding patient care? Most of the time we have an in-service to let them know what the family is requesting. I care plan it so everyone will know /they are well-informed so that the message is passed on . Resident #1 is an unusual incident I don't tolerate abuse, why should I want to be abused, this is something I will regret. During a face-to-face interview with Employees' #1 and #2 on (MONTH) 19, 2019 they stated, We conducted the investigation of (Resident #1). He (Employee # 4) was the only person involved in the incident. There were no witnesses. The Employee was suspended immediately. He was sent for education/in-services and returned to work on (MONTH) 27, 2019 at 7:28 AM. We believe what he (Employee #4) said about what happened. He probably could have called for additional help. We maintain the actions of Employee #1 (CNA) were not abusive (willful) but a care issue. We still believe it's a care issue. The writer asked, is it my understanding that the Resident only wanted female CNAs? Employees' #1 and #2 stated, The unit manager got the note (from the family), the note was received before this incident requesting that the resident (Resident #164) not have a male CN[NAME] The writer asked, what was the outcome of the investigation? Employees' #1 and #2 stated, The Employee needed further education on combative residents and dignity and monitoring during care. The writer asked, how were they monitoring Employee #4? Employees' #1 and #2 stated, They were asking the charge nurses how the employee was doing. The monitoring started immediately (upon his return to work on (MONTH) 27, 2019). There was no monitoring tool. They would touch basis on the days he worked to ensure he was fine. The writer asked, why was the Employee terminated on (MONTH) 16, 2019? Employee #1, stated, he was terminated on (MONTH) 16, 2019, as a result of the DC Department of Health Complaint Investigation Report (C-19-057, DC-4819, harm level deficiency cited), gross negligence, carelessness, failure to follow the policy and procedure in the care of a resident. We could have done better. Summary of Findings: The facility failed to provide an interpreter to communicate with the resident while providing health care services (ADL care) Per the MDS dated (MONTH) 3, 2019. The facility failed to provide two (2) person physical assistant when performing adl care for Resident #4 on (MONTH) 16, 2019, Per the MDS dated (MONTH) 3, 2019. The facility staff failed to ask why Resident #164's family did not want male CNAs caring for the resident. The facility staff failed to have written documentation that staff were in-serviced on the family's wishes not to have male CNAs care for Resident #164. The facility CNA staff failed to follow their resident care assignments given by the Charge Nurse on (MONTH) 16, 2019. Employee #4 (CNA) failed to stop caring for Resident #164 who became combative during ADL care on (MONTH) 16, 2019. Employee #4 failed to call for assistance when Resident #164 became combative on (MONTH) 16, 2019. The facility's investigation lacked evidence such as, the supervisor's written account of what occurred and how Employee #4 was supervised/managed after the incident, and a written statement from Employee #4 at the time of the incident stating what occurred during care of the resident. There was no formal written summary/conclusion of the facility's investigation. The facility administrative staff failed to thoroughly investigate and recognize the incident on (MONTH) 16, 2019 as a likelihood of abuse or neglect. The administrative staff, however, identified the incident on (MONTH) 16, 2019 as a care issue. The facility's administration received the survey findings from the (DC Department of Health) complaint report, and as a result of the findings Employee #4 was terminated on (MONTH) 16, 2019 for gross negligence, carelessness, and failure to follow the policy and procedure in the care of a resident. Employee #4 worked 33 hours providing care to other residents from (MONTH) 27, 2019 to (MONTH) 16, 2019, prior to being terminated. During the face-to-face interview on (MONTH) 23, 2019 approximately at 2:15 PM, Employees' #1 and #2 acknowledged the findings.",2020-09-01
6,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,641,D,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview for one (1) of 56 sampled residents, facility staff failed to accurately code the Comprehensive Minimum Data Set (MDS) for one (1) resident with a [DIAGNOSES REDACTED]. Findings included . Resident #175 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] showed Resident #175 is cognitively intact as evidenced by a Brief Interview for Mental Status score of 15. Review of the physician's orders [REDACTED]. Further review of the MDS showed Section I Active Diagnoses: [REDACTED]. Facility staff failed to accurately code the MDS to include resident's active [DIAGNOSES REDACTED]. During a face-to-face interview on 7/29/19 at 11:30 AM Employee #12 acknowledged the finding and stated yes, the resident has [MEDICAL CONDITION] I will make the change now.",2020-09-01
7,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,645,D,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents, it was determined that facility staff failed to ensure that the resident on admission was referred to the appropriate state-designated authority for a Level II Pre-Admission Screen/Resident Review for Mental Illness and or Mental [MEDICAL CONDITION] evaluation and determination. Resident #7. Findings included . A review of the Pre-Admission Screening/Resident Review for Mental Illness and or Mental [MEDICAL CONDITION] Level I (PASRR) screen, signed as completed by the facility staff on (MONTH) 31, 2014, revealed that Resident #7 was identified as positive for major mental disorder [MEDICAL CONDITION], and a Level II screen is required. There is no evidence that the facility staff completed the Level II Pre-Admission Screening/Resident Review as indicated from the level I screening. Facility staff failed to ensure that the Level 2 Pre-Admission Screen/Resident Review for Mental Illness and or Mental [MEDICAL CONDITION] for Resident #7 who had a [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee #11 (SW) on 7/25/2019 at 9:00 AM. After a review of the findings she acknowledged that the level II screening was not done.",2020-09-01
8,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,655,E,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to ensure that a baseline care plan included goals and approaches needed to provide effective and person-centered care for one (1) resident who has [MEDICAL CONDITION] to the right arm. Resident # 235 Findings included . Facility staff failed to ensure that Resident #235 who has a [DIAGNOSES REDACTED]. Resident #235 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. 5) Elevate r (right) arm with pillow to reduce [MEDICAL CONDITION]. Review of the facility's 48-hour baseline care plan showed the care plan was initiated on 6/20/19; however, there are no goals or approaches to address the care or the resident's right arm. During a face-to-face interview conducted on 7/25/19 at 3:28 pm, with Employee #16, she acknowledged the findings.",2020-09-01
9,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,656,D,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1 ) of 56 sampled residents, facility staff failed to develop a care plan with goals and approaches to properly care for one (1) resident who has a negative pressure dressing/device on her right knee. Resident # 545. Findings included . Facility staff failed to ensure that Resident #545 had a care plan to address the use of a negative pressure dressing and device. Resident #545 was admitted to the facility on (MONTH) 12, 2019, with diagnoses, which included Presence of right artificial knee joint, obesity, and [MEDICAL CONDITION] disorder. The physician's orders [REDACTED]. Monitor site for drainage and signs of infection (every) shift. On (MONTH) 18, 2019 at approximately 9:40 AM, Resident #545 was observed sitting in a wheelchair in her room with the negative pressure dressing/device placed over her right knee. Review of Resident #545's care plan lacked evidence of problem/focus area with goals and approaches to address the care of treatment of [REDACTED]. The findings were acknowledged during a face-to-face interview with Employee #16 on (MONTH) 22, 2019 at approximately 3:40 PM.",2020-09-01
10,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,657,E,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review for three (3) of 56 sampled residents, facility staff failed to revise care plan for one (1) resident diagnosed with [REDACTED]. Residents' #58, #155 and #182 Findings included 1. Facility staff failed to update/revise the care plan with resident-centered goals and approaches for care of Resident #58 with an indwelling Foley catheter who developed an penile injury. Resident #58 was admitted to facility on 1/27/15, with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION]. A review of the Quarterly MDS (Minimum Data Set) dated 4/16/19 showed, Section C (Cognitive) - BIMS score 05 indicating resident has severe cognitive impairment. Section G Functional Status the resident was coded as needing total assistance with one to two person support and care under toileting. Section H Bladder/Bowel - Appliances was coded to indicate resident has indwelling urinary draining device. A review of NP (Nurse Practitioner) progress note dated 5/31/2019 revealed, .10:36 PM Pt with UR, observed during day, unable to pee, Foley reinserted able to drain urine. Penis lacerated from previous Foley catheter with ulcer at glans Pt states pain burning at penis. Purulent drainage from penis . Foley inserted attached to right leg to avoid further laceration at left side Avoid diaper when patient has Foley (to lacerate penis). There was no evidence facility staff revised care plan to include care of penile laceration and erosion. The findings were acknowledged during a face-to-face interview with Employee #3 (Unit Manager) on (MONTH) 29, 2019 at 11:00 AM. 2. Facility staff failed to update/revise the care plan with resident-centered goals and approaches for care of Resident #155 percutaneous endoscopic gastrostomy (PEG) tube. Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed resident Brief Interview for Mental Status (BIMS) is coded as 6 to indicate moderately impaired cognition. Further review of the MDS showed Section K (Swallowing/Nutritional Status) Nutrition Approach resident is coded as having a feeding tube. On 7/25/19 at 3:00 PM review of the care plan failed to show goals and approaches for care of Resident #155 percutaneous endoscopic gastrostomy (PEG) tube. During an interview on 7/25/19 at 3:00 PM, Employee# 13 acknowledged the findings. 3.Facility staff failed to update/revise the care plan with resident-centered goals and approaches for care of Resident #182 who sustained a fall with injury. Resident #182 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. A review of Resident #182's admission Minimum Data Set ((MDS) dated [DATE], showed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) with a score of 11 which indicated the resident had moderate cognitive impairment. Section G (Functional Status) resident is coded as 3 extensive assistance (resident involved in activity staff provide weight-bearing support) for bed mobility, transfer, locomotion on the unit and locomotion off the unit. A review of the Resident's progress note dated 7/7/19 showed the following: 7/9/19 1:51 PM Nurse Practitioner Progress note; Pt c/o pain today at left leg . x-ray ordered . pain with ROM at left leg at knee part, had pain earlier at left hip, slight swelling left leg and lower thigh, x-ray left leg. 7/10/19 9:52 AM Nurse's late entry for 7/9/19 Resident is status [REDACTED]. Seen by the NP .due to complaint of pain on the left hip that radiates to the lower extremity. As result, x-ray of the left hip, left femur and left knee was ordered. X-ray was done at 3 pm, preliminary x-ray result showed resident has [MEDICAL CONDITION] femur NP was notified An order to transfer resident to the emergency room . A review of the care plan initiated on 5/17/19 showed resident at risk for falling r/t (related) cognitive impairment, unsteady gait and [DIAGNOSES REDACTED]. resident was observe on the floor with no injury. Further review of the fall care plan on (MONTH) 25, 2019 failed to show any evidence that the facility reviewed and revised the care plan after the resident sustained [REDACTED]. During a face-to-face interview with Employee #13 on 7/26/19, at 1:44 PM, he acknowledged the findings",2020-09-01
11,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,658,D,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Medpass observation and interview for one (1) of 56 sampled residents, the facility staff failed to provide care in accordance with professional nursing standards as evidenced by the staff was observed using the blood pressure machine incorrectly to measure one (1) resident's blood pressure. Resident #14. Findings included . According to the American Heart Association: Accurate measurement of blood pressure is essential to classify individuals, to ascertain blood pressure-related risk, and to guide management. Selection of the correct cuff size, and proper patient positioning if accurate blood pressures are to be obtained . In view of the consequences of inaccurate measurement, regulatory agencies should establish standards to ensure the use of validated devices, routine calibration of equipment, and the training and retraining of manual observers. Retrieved from: www.ahajournals.org/doi/full/10.1161/01.HYPXXX XXX .8e Resident #14 was admitted to the facility on (MONTH) 27, (YEAR), with diagnoses, which include [MEDICAL CONDITION], Neoplasm of Prostate, Cardiomegaly, Hypertension, [MEDICAL CONDITION], and Coronary [MEDICAL CONDITION]. A review of the Quarterly Minimum Data Set (MDS) dated (MONTH) 3, 2019, Section C0500 (BIMS (Brief Interview for Mental Status) Summary Scores) of 12 Moderately impaired which indicates, Resident unable to make decisions. During Med pass observation on (MONTH) 23, 2019, at 8:55 AM, Employee #10 was observed using the blood pressure machine incorrectly to measure Resident # 14's blood pressure and to walk away out of the room, leaving the resident's medication at the bedside prior to administering the resident his medication. The employee used an automatic digital blood pressure machine provided by the facility for measuring residents blood pressure. Observation showed the blood pressure machine had a problem measuring Resident #14's blood pressure. Employee#17 removed and reapplied the digital upper arm blood pressure cuff to the resident's forearm to measure the resident's blood pressure. At the time of the observation, Employee #17 was asked what is the process used for applying a blood pressure cuff to measure the blood pressure. Employee #17 was able to verbalize the process used to measure the resident blood pressure and concluded that the machine was having a problem. At the time of the observation, Employee #, 17 did not recheck the resident's blood pressure for accuracy. A face-to-face interview was conducted on (MONTH) 23, 2019, at approximately 10:15 AM, with Employee #18 and Employee #17. Both employees acknowledged the findings.",2020-09-01
12,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,684,D,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents facility's staff failed to ensure the resident received treatment and care in accordance with professional standards of practice as evidenced by failure to ensure that Resident #548 was seen by the orthopedic physician in a timely manner. Findings included . Resident #548 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a face-to-face interview with Resident #548 on 7/17/19 he stated, I have not had a follow up appointment related to my fractured toe(s). When I spoke with the facility, they stated the hospital did not give them the appointment date. I have not seen the orthopedic surgeon since I have been here and I do not have an appointment. Review of the discharge summary from the hospital dated 7/10/19, showed, .(Resident #548) should remain NWB (Non weight bearing) LLE (left lower extremity) and elevate LLE when not ambulating .Follow up with (Doctor Name) in 7-10 days after discharge. Splint should remain in place and will get repeat x-rays in ortho clinic in 2 weeks. The physician's orders [REDACTED].Schedule appointment to follow up with orthopedic . The facility staff failed to schedule Resident #548 for a follow up orthopedic appointment in a timely manner. During a face-to-face interview with Employee #16 on 7/22/19, at 2:12 PM, she (nurse manager) stated the appointment has not been made. He did not come with an appointment date. Employee #16 then reviewed the discharge summary and stated, We will make the appointment today. The facility staff failed to ensure that Resident #548 was seen by the orthopedic physician within 7 -10 days after he was discharged from the hospital.",2020-09-01
13,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,689,G,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents, facility staff failed to ensure one (1) resident who was identified as a fall risk received adequate supervision. The resident was left unattended in the solarium where he subsequently fell from his wheel chair and sustained a left Femur fracture. Resident #182 Findings included . A review of the Resident's Clinical record showed that on (MONTH) 7, 2019, at 11: 00 AM Resident #182 was left unattended in the solarium where he subsequently fell from his wheel chair and sustained a left Femur fracture. Resident #182 was admitted to the facility on (MONTH) 15, 2019, with [DIAGNOSES REDACTED]. A review of Resident #182's admission Minimum Data Set ((MDS) dated [DATE], showed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) with a score of 11 which indicates the resident had moderate cognitive impairment. Section G (Functional Status) resident is coded as 3 extensive assistance with one (1) person physical assist for bed mobility, transfer, locomotion on the unit and locomotion off the unit. Section G 0400 Functional Limitation in Range of motion code 0 indicates No impairment. Section J I700 Fall History on Admission/entry was coded as1 to indicate that the resident had a fall 2 - 6 months prior to his admission to the facility. A review of the care plan initiated on 5/17/19 showed resident at risk for falling r/t (related) cognitive impairment, unsteady gait and [DIAGNOSES REDACTED]. resident was observe on the floor with no injury. There was no mention that Resident #182 had a fall on 7/7/19. A review of the Resident's progress note showed the following: 7/7/19/ 1:41 PM Writer (RN Supervisor) was called to unit 3 green and noted resident in a sitting position in front of his wheel chair in the solarium. Upon assessment resident denied pain or discomfort, no injury noted, denied hitting his head able to move his upper arm and lower extremities without difficulty to his baseline. Resident was asked how he got to the floor he said that he did not know 7/9/19 1:51 PM NP's (Nurse Practitioner's) Progress note showed Pt c/o pain today at left leg . x-ray ordered . pain with ROM at left leg at knee part, had pain earlier at left hip, slight swelling left leg and lower thigh, x-ray left leg. 7/10/19 9:52 AM (RN) late entry for 7/9/19 Resident is status [REDACTED]. Seen by the NP .due to complaint of pain on the left hip that radiates to the lower extremity. As result, x-ray of the left hip, left femur and left knee was ordered. X-ray was done at 3 pm, preliminary x-ray result showed resident has [MEDICAL CONDITION] femur NP was notified An order to transfer resident to the emergency room . A review of the result of the stat x-ray of left femur, left knee, left hip and pelvis on 7/9/19 ordered by NP showed Impression: Acute [MEDICAL CONDITION] Left Femur. A face to face interview was conducted on 7/26/19 at 1:55 PM with Employee #19 (CNA) who stated, I was in the solarium watching and monitoring residents when my coworker in the room next to the solarium asked me for help to put a resident in chair. I left the solarium to the room right outside the solarium to help with another resident. While in the room I heard someone say resident on the floor in solarium and ran back in there he was sitting on the floor in front of wheel chair. On Tuesday I was giving AM care when I went to move him he says ouch, ouch. I asked what was wrong he pointed to left side of hip. I called charge nurse and she came to see him. Another face to face interview was conducted on 7/26/19 at 1:59 PM with Employee #20 (CNA) who stated, I was in (resident,s name) room getting her ready to get out of bed, (CNA name) in solarium covering residents in solarium. I had went to her to ask her to help me put (resident's name) in chair. She did and while in room another resident called out patient on floor. We both ran out to solarium he was sitting up on the floor beside his wheel chair. He did not complain staff came and assessed him. The evidence showed that facility staff failed to ensure one (1) resident who sustained a fall with an injury received adequate supervision to prevent an accident as evidenced by the staff assigned to watch and monitor the residents in the solarium left him unattended. During a face-to-face interview with Employee #13 (unit manager) on 7/26/19, at 1:44 PM, he acknowledged the findings and stated, The staff assigned to the solarium left to help a coworker although we educate them not to leave residents in the solarium alone.",2020-09-01
14,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,690,G,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and staff interviews for one (1) of 56 sampled residents, the facility staff failed to provide appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. Findings included . Wound, Ostomy and Continence Nurses Society. (2016). Care and management of patients with urinary catheters: A clinical resource guide. MT. Laurel: N[NAME] Author Securement Devices: .Indwelling catheters should be secured to avoid traction on the catheter, which causes irritation and trauma to the urethra(e.g., urethritis, necrosis, erosion, stricture) .monitor the urethra daily for irritation, erosion, or urine leakage and assess the skin integrity under the securement device. Resident #58 was readmitted to facility on 12/21/18, with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION]. A review of the Comprehensive MDS (Minimum Data Set) dated 4/16/19 showed, Section C (Cognitive) - BIMS score 05 indicating resident has severe cognitive impairment. Section G Functional Status the resident was coded as needing total assistance with one to two person support and care under toileting. Section H Bladder/Bowel - Appliances was coded to indicate resident has indwelling urinary draining device. A review of the care plan for Foley Catheter due to [MEDICAL CONDITION] showed it was initiated on 1/23/2019. Goal: resident will have catheter care managed appropriately .not exhibiting signs of urinary tract infection or urethral trauma. Approach: .report signs of UTI .manipulate tubing as little as possible during care .provide catheter care .use catheter strap .use leg bag as needed . A review of Medical Record Revealed: A physician's orders [REDACTED]. Urology consult for UR 12/10/2018. Urology Consult-1/3/2019, Diagnosis; [MEDICAL CONDITION] with chronic indwelling Foley catheter and urethral erosion. A review of NP (Nurse Practitioner) progress note dated 5/31/2019, revealed, .10:36 PM Pt with UR, observed during day, unable to pee, Foley reinserted able to drain urine. Penis lacerated from previous Foley catheter with ulcer at glans Pt states pain burning at penis. Purulent drainage from penis . Foley inserted attached to right leg to avoid further laceration at left side avoid diaper when patient has Foley (to lacerate penis). 5/31/2019 - Interim Order, Please avoid diaper when pt. has a Foley (cause Laceration of penis) Foley inserted routine Foley care q shift. A review of NP Progress note dated 6/4/2019, .Pt with Foley catheter with ulcer of glans purulent drainage from penis . 6/5/2019- Interim Order, D/C order to avoid diaper when pt. has a Foley Use diaper to make it loose to prevent laceration. Urology Consult for possible Suprapubic catheter (6/20/2019) .Progress note [MEDICAL CONDITION] UTI (Urinary .Penile erosion .plan for SP (Suprapubic) tube placement under local . Urology consultation for [MEDICAL CONDITION] at (Hospital Name) at 1:30 PM with (Physician name) (07/03/19). Change Foley catheter q 6 weeks obtain medical records or other history to determine if there are reasonable alternative to indwelling Foley catheter . 7/5/2019- Urology Consult findings: S/P tube inserted under u/s (ultrasound) guidance New Diagnosis: [REDACTED].urethral erosion. 7/9/ 2019- Interim Order urology F/U (follow up) for Suprapubic Cath . Upon review of the nursing progress notes dated (MONTH) 1, 2019 through (MONTH) 30, 2019 showed no evidence the facility staff assessed the resident's [MEDICAL CONDITION] status for complications (irritation and trauma to the penis or urethra) regarding indwelling Foley catheter prior to or after the penile laceration and erosion occurred and was documented by Nurse Practitioner resulting in the surgical insertion of the suprapubic catheter directly in to the Residents bladder for further care. Through record review, it was noted the resident was diagnosed with [REDACTED]. There was no evidence that facility staff conducted an initial and ongoing [MEDICAL CONDITION] assessment (size, discoloration of skin, odor, swelling, pain, drainage) and treatment plan to promote healing. On 5/31/19, the resident was noted with a laceration to his penis from previous Foley catheter with ulcer at glans, with pain burning and purulent drainage from penis. On 7/5/19, the resident had a suprapubic catheter inserted due to [MEDICAL CONDITION] and urethral erosion. The findings were acknowledged on (MONTH) 29, 2019, at 10:00 AM during a face-to-face interview with Employee # 3 who stated she did not know what erosion was and would look it up on the internet.",2020-09-01
15,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,693,D,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview for one (1) of 56 sampled residents facility staff failed to provide evidence of providing care for one (1) resident's percutaneous endoscopic gastrostomy (PEG) site. Resident #155. Findings included . Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed resident Brief Interview for Mental Status (BIMS) is coded as 6 to indicate moderately impaired cognition. Further review of the MDS showed Section K (Swallowing/Nutritional Status) Nutrition Approach resident is coded as having a feeding tube. Percutaneous Endoscopic Gastrostomy (PEG) is a medical procedure in whch a tube is passed into a patient's stomach to provide a means of feeding when oral intake is not adequate. Review of the nurses note on 6/28/19 showed resident went to the emergency room via non-emergency ambulance for evaluation. Review of (Hospital name) transfer summary dated 7/3/19 showed the patient was found to have skin excoriation and some pus discharge around the PEG tube site on admission. Further review of the transfer summary showed discharge plan please continue the PEG care at the nursing home, clean the area around the PEG tube. Observation on 7/26/19 at 11:30 AM of Resident #155 PEG site showed PEG tube insertion site without a dressing in place or evidence the site was cleaned. During an interview on 7/26/19, at 11:30 AM Employee #13 was asked if nurses were providing PEG site care? Employee #13, I did not see this on the transfer summary, I will let the doctor know right away. Review of the medical record showed no documented evidence facility staff are cleaning around the PEG site. Facility staff failed to provide evidence of providing skin care to PEG site to maintain infection control practices. During a face-to-face interview on 7/26/19 at 11:30 AM, Employee #13 acknowleged the finding.",2020-09-01
16,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,726,E,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews for two (2) of 56 sampled residents, the facility staff failed to provide competent nursing staff to care for one (1) resident with an indwelling Foley catheter who developed an penile injury; and failed to ensure nursing staff has specific competencies and skills to assess and care for one (1) resident who is [MEDICAL TREATMENT]-dependent and has a arteriovenous (AV) fistula graft site. Residents' #58 and #175. Findings included . 1. Facility staff failed to provide competent nursing staff to care for Resident #58 with an indwelling Foley catheter who developed an penile injury. Wound, Ostomy and Continence Nurses Society. (2016). Care and management of patients with urinary catheters: A clinical resource guide. MT. Laurel: N[NAME] Author Securement Devices: .Indwelling catheters should be secured to avoid traction on the catheter, which causes irritation and trauma to the urethra(e.g., urethritis, necrosis, erosion, stricture) .monitor the urethra daily for irritation, erosion, or urine leakage and assess the skin integrity under the securement device. Resident #58 was readmitted to facility on 12/21/18, with [DIAGNOSES REDACTED]., Depression, [MEDICAL CONDITION]. A review of the Comprehensive MDS (Minimum Data Set) dated 4/16/19 showed, Section C (Cognitive) - BIMS score 05 indicating resident has severe cognitive impairment. Section G Functional Status the resident was coded as needing total assistance with one to two person support and care under toileting. Section H Bladder/Bowel - Appliances was coded to indicate resident has indwelling urinary draining device. A review of the care plan for Foley Catheter due to [MEDICAL CONDITION] showed it was initiated on 1/23/2019. Goal: resident will have catheter care managed appropriately .not exhibiting signs of urinary tract infection or urethral trauma. Approach: .report signs of UTI .manipulate tubing as little as possible during care .provide catheter care .use catheter strap .use leg bag as needed . A review of Medical Record Revealed: A physician's orders [REDACTED]. Urology consult for UR 12/10/2018. Urology Consult-1/3/2019, Diagnosis; [MEDICAL CONDITION] with chronic indwelling Foley catheter and urethral erosion. A review of NP (Nurse Practitioner) progress note dated 5/31/2019, revealed, .10:36 PM Pt with UR, observed during day, unable to pee, Foley reinserted able to drain urine. Penis lacerated from previous Foley catheter with ulcer at glans Pt states pain burning at penis. Purulent drainage from penis . Foley inserted attached to right leg to avoid further laceration at left side avoid diaper when patient has Foley (to lacerate penis). 5/31/2019 - Interim Order, Please avoid diaper when pt. has a Foley (cause Laceration of penis) Foley inserted routine Foley care q shift. A review of NP Progress note dated 6/4/2019, .Pt with Foley catheter with ulcer of glans purulent drainage from penis . 6/5/2019- Interim Order, D/C order to avoid diaper when pt. has a Foley Use diaper to make it loose to prevent laceration. Urology Consult for possible Suprapubic catheter (6/20/2019) .Progress note [MEDICAL CONDITION] UTI (Urinary .Penile erosion .plan for SP (Suprapubic) tube placement under local . Urology consultation for [MEDICAL CONDITION] at (Hospital Name) at 1:30 PM with (Physician name) (07/03/19). Change Foley catheter q 6 weeks obtain medical records or other history to determine if there are reasonable alternative to indwelling Foley catheter . 7/5/2019- Urology Consult findings: S/P tube inserted under u/s (ultrasound) guidance New Diagnosis: [REDACTED].urethral erosion. 7/9/ 2019- Interim Order urology F/U (follow up) for Suprapubic Cath . Upon review of the nursing progress notes dated (MONTH) 1, 2019 through (MONTH) 30, 2019 showed no evidence the facility staff assessed the resident's genital-urinal status for complications (irritation and trauma to the penis or urethra) regarding indwelling Foley catheter prior to or after the penile laceration and erosion occurred and was documented by Nurse Practitioner resulting in the surgical insertion of the suprapubic catheter directly in to the Residents bladder for further care. Through record review, it was noted the resident was diagnosed with [REDACTED]. There was no evidence that facility staff conducted an initial and ongoing [MEDICAL CONDITION] assessment (size, discoloration of skin, odor, swelling, pain, drainage) and treatment plan to promote healing. On 5/31/19, the resident was noted with a laceration to his penis from previous Foley catheter with ulcer at glans, with pain burning and purulent drainage from penis. On 7/5/19, the resident had a suprapubic catheter inserted due to [MEDICAL CONDITION] and urethral erosion. The findings were acknowledged on (MONTH) 29, 2019, at 10:00 AM during a face-to-face interview with Employee # 3 who stated she did not know what erosion was and would look it up on the internet. 2. Facility staff failed to ensure nursing staff has specific competencies and skills to assess and care for a [MEDICAL TREATMENT]-dependent arteriovenous (AV) fistula graft site. Resident #175. Record review of the facility's undated policy titled, Care of Resident Receiving [MEDICAL TREATMENT] showed the nurse will check the thrill/bruit at the access site every shift. Caring for a Patient's Vascular Access for [MEDICAL TREATMENT]: Assess for patency at least every eight hours. Palpate the vascular access to feel for a thrill or vibration that indicates arterial and venous blood flow and patency. Auscultate the vascular access with a stethoscope to detect a bruit or swishing sound that indicates patency. Retrieved from: Nursing Management (2011). Resident #175 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE], showed resident Brief Interview for Mental Status (BIMS) is coded as 15 to indicate cognitively intact. Further review of the MDS showed Section O (Special Treatments, Procedures and Programs) resident is coded as receiving [MEDICAL TREATMENT]. Review of physician's orders [REDACTED]. Review of resident's care plan showed, [MEDICAL TREATMENT] Dependent: monitor [MEDICAL TREATMENT] arteriovenous fistula (AV) to left arm for bruit, thrill and bleeding. Review of the nursing assessment notes of the AV fistula site showed the following entries: 5/5/19: Thrill/Trust present. 5/14/19: No infection, thrill/trust present. 6/4/19: Thrill/Trust present at this time. 6/11/19: No infection noted, thrill/trust present. 7/16/19: Thrill/Trust was present. 7/17/19: Thrill/Trust present. On 7/25/19, at 1:00 PM an interview with Employee #15 in the presence of Employee #14. Employee #15 was asked how do you assess the resident's AV graft site. Employee #15 stated, I look for infection and bleeding. Employee #15 was asked what is a trust? Employee responded, That is when the blood is going back and forth. Employee #15 was asked do you use a stethoscope when assessing the AV fistula site. Employee #15 responded, No. There is no evidence the nurse assessing the AV fistula has the skill or competency to provide care in accordance with professional standards of practice; review of the medical showed there was no harm to the resident. At the time of the interview on 7/25/19, at 1:00 PM Employee#14 and Employee #15 acknowledged the finding.",2020-09-01
17,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,740,E,0,1,BMNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled residents facility staff failed to provide the necessary behavioral health care services and antidepressant medication for Resident #63 to attain the highest practicable physical, psychosocial and mental well-being in accordance with the comprehensive assessment and plan of care. Findings included Resident #63 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE], showed Resident #63's Brief Interview for Mental Status (BIMS) is coded as 15 to indicate she is cognitively intact. Further review of the MDS showed Section D (Mood) resident is coded as 1 to indicate the presence of the following symptoms: feeling down, depressed or hopeless, trouble concentrating on things, poor appetite, trouble falling or staying asleep .Section I (Active Diagnoses) showed Psychiatric/Mood Disorder, Depression is selected. Section N (Medications) Antidepressants is not selected to indicate resident did not receive antidepressant medication. Review of the Social Service note dated 7/19/19, showed resident stopped this social worker stating that she took [MEDICATION NAME] in the past but has not, since being admitted . During a resident interview on 7/24/19, at 4:00 PM, Resident #63 stated, I told the nurse that I was on an antidepressant and I have not been getting my medicine and I have nightmares. Resident denied wanting to harm herself or others. Review of the physician's orders [REDACTED]. During an interview on 7/24/19, at 4:30 PM with the Employee #13 stated, She is care planned for depression but no she is not on medication or seeing the psychiatrist, I will get on this right away. Observations during survey period (7/17/19 through 7/30/19) showed resident participating in activities daily and talking with other residents. Facility staff failed to provide the necessary behavioral health care and services (to include medications) to a resident with a Major [MEDICAL CONDITION]. Review of the medical record showed there was no harm to the resident. During a face-to-face interview on 7/24/19, at 4:30 PM, Employee #13 acknowledged the finding.",2020-09-01
18,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,755,D,0,1,BMNI11,"Based on record review and staff interviews for two (2) of nine (9) nursing units, the facility staff failed to ensure that the system use for acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was followed. Findings included . A review of the Shift count Narcotic records on Unit 1 Green was completed on (MONTH) 19, 2019, at approximately 9:00 AM. The review showed that on (MONTH) 5, 2019, the Shift count Narcotic was missing a nurse signature (indicating it was not done) in the space allotted the nurse going off duty to reconcile the Narcotics for the 7:30 AM to 3:30 PM shift. A review of the Shift count Narcotic records on Unit 1 Orange was completed on (MONTH) 19, 2019, at approximately 9:10 AM. On (MONTH) 12, 2019, the Narcotic count sheet, showed the spaces allotted for nurse signature going off duty to reconcile the Narcotics for the 11:00 PM to 7:30 AM shift was left blank indicating Not Done. A review of the Shift Verification of Accuracy of Controlled Drug Record to the Actual Narcotic Count (Reconciliation Controlled Drug Count Verification Form) directed, Shift count sheet for Narcotics balance must be verified by the nurse coming on duty and nurse going off duty at each change of shift The evidence showed that the system's use for acceptable standard of practice to account for the receipt, usage, disposition, and reconciliation of controlled medications was not followed. A face-to-face interview was conducted with Employee #5 on (MONTH) 26, 2019, at approximately 11:10 AM. After a review of the documentation, she acknowledged the findings.",2020-09-01
19,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,812,E,0,1,BMNI11,"Based on observations and staff interview, the facility failed to prepare foods under sanitary conditions as evidenced by four (4) of four (4) soiled fire sprinklers heads, one (1) of four (4) damaged sprinkler head, a water fountain with a missing cover and erroneous dish machine final rinse temperature documentation. Findings included . During a walkthrough of the facility's dietary services on (MONTH) 17, 2019, at approximately 8:10 AM: 1. Four (4) of four (4) fire sprinklers located above the tilt skillet, the grill, the grease fryer and the stove were soiled with a sticky, oily sludge. 2. One (1) of four (4) fire sprinkler heads located above the tilt skillet was bent at the deflector. 3. The water fountain located in the main kitchen lacked an enclosure to protect its internal parts and provide a safety barrier. 4. Dish Machine Temperature logs from (MONTH) 2019 through (MONTH) 2019 were inaccurately recorded. Final Rinse temperatures were consistently documented at less than 180 degrees Fahrenheit (F) on 19 occasions in (MONTH) 2019, 76 times in (MONTH) 2019, 81 times in (MONTH) 2019, 80 times in (MONTH) 2019, and 79 times in (MONTH) 2019, and twice in (MONTH) 2019. During a face-to-face interview with Employee #8 on (MONTH) 26, 2019, at approximately 11:00 AM and Employee #9 on (MONTH) 26, 2019, at approximately 12:15 PM, they both acknowledged there were no mechanical breakdowns with the dish machine when the above final rinse temperatures were recorded at less than 180 degrees Fahrenheit (F). Dish Machine temperatures are recorded two (2) to three (3) times daily according to the Dish Machine Temperature logs. Employee #8 acknowledged the above findings during a face-to-face interview on (MONTH) 26, 2019, at approximately 11:00 AM.",2020-09-01
20,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,835,F,0,1,BMNI11,"Based on staff interview, Administration failed to ensure that action plans were developed and implemented to ensure that facility staff thoroughly investigated the incident which caused Resident #1 to sustained an orbital fracture and multiple bruises during am care as a potential for abuse, neglect. Administration, failed to ensure facility staff implemented measures to prevent further potential abuse, neglect from occurring to other residents within the facility; and as a result of their investigation appropriate corrective action was not taken in accordance with the facility's Abuse policy. Also, Administration failed to ensure that the facility staff provided adequate supervision to prevent an accident for Resident #182 who had a fall with an injury and to provide appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. The census on the first day of survey was 243. Findings included . 1.In the area of 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. Administration failed to thoroughly investigate the incident which caused Resident #1 to sustained an orbital fracture and multiple bruises during am care as a potential for abuse, neglect. In addition, the facility failed implement measures to prevent further potential abuse, neglect from occurring to other residents within the facility; and as a result of their investigation appropriate corrective action was not taken in accordance with the facility's Abuse policy. On (MONTH) 23, 2019, at 11:09 AM an Immediate Jeopardy (IJ)-L was identified at 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. During the face-to-face interview on (MONTH) 23, 2019 approximately at 2:15 PM, Employees' #1 and #2 acknowledged the findings. Cross reference 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. 2. In the area of 42 CFR 483.25(d)(1)(2), F689 Free of Accident Hazards/Supervision/Devices, the Administration failed to ensure that the facility staff provided adequate supervision to prevent an accident for Resident #182 who had a fall with an injury. During a face-to-face interview with Employee #13 on 7/26/19, at 1:44 PM, he acknowledged the findings and stated, The staff assigned to the solarium left to help a coworker although we educate them not to leave residents in the solarium alone. Cross Reference 42 CFR 483.25(d)(1)(2), F689 Free of Accident Hazards/Supervision/Devices 3. In the area of 42 CFR 483.25(e)(1)-(3), F690 Bowel/bladder/Incontinence, Catheter, UTI, the Governing Body failed to ensure facility staff provided appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. The findings were acknowledged on (MONTH) 29, 2019, at 10:00 AM during a face-to-face interview with Employee #3 (Unit manager) who stated she did not know what erosion was and would look it up on the internet. Cross reference 42 CFR 483.25(e)(1)-(3), F690 Bowel/bladder/Incontinence, Catheter, UTI",2020-09-01
21,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,837,F,0,1,BMNI11,"Based on staff interview, Governing Body failed to ensure that action plans were developed and implemented to ensure that facility staff thoroughly investigated the incident which caused Resident #1 to sustained an orbital fracture and multiple bruises during am care as a potential for abuse, neglect. The Governing Body failed to ensure facility staff implemented measures to prevent further potential abuse, neglect from occurring to other residents within the facility; and as a result of their investigation appropriate corrective action was not taken in accordance with the facility's Abuse policy. Also, the Governing Body failed to ensure that the facility staff provided adequate supervision to prevent an accident for Resident #182 who had a fall with an injury and to provide appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. The census on the first day of survey was 243. Based on record review and staff interview for two (2) of 56 sampled residents facility staff failed to ensure one (1) resident who had a fall with an injury received adequate supervision to prevent an accident. Resident #182 Findings included . 1.In the area of 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. The Governing Body failed to thoroughly investigate the incident which caused Resident #1 to sustained an orbital fracture and multiple bruises during am care as a potential for abuse, neglect. In addition, the facility failed implement measures to prevent further potential abuse, neglect from occurring to other residents within the facility; and as a result of their investigation appropriate corrective action was not taken in accordance with the facility's Abuse policy. On (MONTH) 23, 2019, at 11:09 AM an Immediate Jeopardy (IJ)-L was identified at 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. During the face-to-face interview on (MONTH) 23, 2019 approximately at 2:15 PM, Employees' #1 and #2 acknowledged the findings. Cross reference 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. 2. In the area of 42 CFR 483.25(d)(1)(2), F689 Free of Accident Hazards/Supervision/Devices, the Governing Body failed to ensure that the facility staff provided adequate supervision to prevent an accident for Resident #182 who had a fall with an injury. During a face-to-face interview with Employee #13 on 7/26/19, at 1:44 PM, he acknowledged the findings and stated, The staff assigned to the solarium left to help a coworker although we educate them not to leave residents in the solarium alone. Cross reference 42 CFR 483.25(d)(1)(2), F689 Free of Accident Hazards/Supervision/Devices 3. In the area of 42 CFR 483.25(e)(1)-(3), F690 Bowel/bladder/Incontinence, Catheter, UTI, the Governing Body failed to ensure facility staff provided appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. The findings were acknowledged on (MONTH) 29, 2019, at 10:00 AM during a face-to-face interview with Employee #3 (Unit manager) who stated she did not know what erosion was and would look it up on the internet. Cross reference 42 CFR 483.25(e)(1)-(3), F690 Bowel/bladder/Incontinence, Catheter, UTI",2020-09-01
22,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,865,F,0,1,BMNI11,"Based on record review and staff interviews, the facility staff failed to develop and implement an effective comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems by failing to implement systems to correct identified problems to ensure that action plans were developed and implemented to ensure that facility staff thoroughly investigated the incident which caused Resident #1 to sustained an orbital fracture and multiple bruises during am care as a potential for abuse, neglect. There was failure to ensure that the facility staff provided adequate supervision to prevent an accident for Resident #182 who had a fall with an injury and to provide appropriate and failure to ensure a process was in place to provide sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter, which resulted in penile erosion and laceration. The facility census was 243 on the first day of the survey. Findings included . During the interview on (MONTH) 30, 2019 at approximately 10:40 AM, a review of the facility ' s quality assurance and performance improvement (QAPI) program was conducted with the facility's administration. The review of the program showed the facility failed to identify concerns, and develop and implement actions plans to correct identified areas of deficient practice in: 42 CFR 483.12 (c)(2)-(4), F610, Investigate/Prevent/Correct/Alleged Violation. Administration failed to thoroughly investigate the incident which caused Resident #1 to sustained an orbital fracture and multiple bruises during am care as a potential for abuse, neglect. In addition, the facility failed implement measures to prevent further potential abuse, neglect from occurring to other residents within the facility; and as a result of their investigation appropriate corrective action was not taken in accordance with the facility's Abuse policy. Employee #5 stated, we review all allegations of resident. 42 CFR 483.25 (d)(1) Accidents -The environment remains as free of accident hazards as is possible; and 483.25 (d)(2) Each resident receives adequate supervision and assistive devices to prevent accidents. Employee #5 stated, resident falls were reviewed. I do a root cause analysis on all falls. The falls committee meets every 3 months, but we are now moving to monthly. We found that most falls occurred at night between 1:55 am to 5:30 AM. The nursing team does a huddle every shift to tell staff who are at risk of falls and the supervisor makes frequent rounds. We have no monitoring tool in place. We have someone in the solarium at all times when the resident are there. The Director of Nursing did a marathon inservice on falls in early (MONTH) (2019). Since then the number of falls reduced in (MONTH) 2019. 42 CFR 483.25(e)(1)-(3), F690 Bowel/bladder/Incontinence, Catheter, UTI, the Governing Body failed to ensure facility staff provided appropriate and sufficient catheter care and assessments and reassessments to prevent Harm for Resident #58 who was admitted with an indwelling Foley catheter which resulted in penile erosion and laceration. Employee #5 stated, we review all wounds, wounds associated from Foley catheter use was not a part of quality assurance program. Staff not reporting information on the 24-hour report- unit mangers not reporting information over to stand up. On (MONTH) 30, 2019, at 10:40 AM, Employee #5 stated the facility made good faith efforts to get things done based on what was reported and acknowledged the findings.",2020-09-01
23,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,908,E,0,1,BMNI11,"Based on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by four (4) of four (4) fire sprinkler heads from the Ansul fire suppression system in the main kitchen that were soiled with grease and one (1) of four (4) fire sprinklers with a bent deflector and a water fountain with a missing cover. Findings included . During a walkthrough of the facility's dietary services on (MONTH) 17, 2019, at approximately 8:10 AM: 1. Four (4) of four (4) fire sprinklers located above the tilt skillet, the grill, the grease fryer and the stove were soiled with a sticky, oily sludge. 2. One (1) of four (4) fire sprinkler heads located above the tilt skillet was bent at the deflector. 3. The water fountain located in the main kitchen lacked an enclosure to protect its internal parts and provide a safety barrier. Employee #8 acknowledged the findings during a face-to-face interview on (MONTH) 26, 2019, at approximately 11:00 AM.",2020-09-01
24,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2019-07-30,919,D,0,1,BMNI11,"Based on observations and staff interview, facility staff failed to maintain the call bell system in good working condition as evidenced by a call bell in two (2) of 65 resident's rooms that failed to alarm when tested . Findings included . During an environmental walkthrough of the facility on (MONTH) 18, 2019, between 10:00 AM and 3:30 PM, the call bell in resident rooms #155A and #309A did not alarm when activated, two (2) of 65 resident's rooms. This breakdown could prevent or delay care to residents in an emergency. Employee #9 acknowledged the above findings during a face-to-face interview on (MONTH) 18, 2019 at approximately 3:00 PM.",2020-09-01
25,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,176,D,0,1,BJXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews for one (1) of 40 sampled residents, the interdisciplinary team failed to assess one (1) resident's ability to self-administer medications in a safe manner. Resident #78. The findings include: On (MONTH) 28, (YEAR) at approximately 10:21 AM Resident #78 was observed opening a dresser drawer in the resident's room and removing the following over-the-counter medications: [REDACTED] a. Two (2) bottles of Anebesol b. One (1) bottle of [MEDICATION NAME] Ultra lubricating eye drop (0.33oz 1 bottle), c. Rolaid 96 chewable tablets, d. Vitron C 60 coated tablets, e. One (1) bottle of Diabetic [MEDICATION NAME] 40 ounces f. One (1) container of Aspercreme g. One (1) Vicks Menthol Inhaler for nasal congestion h. Calcium 600mg plus Vitamin D3800 International Units (100 coated tablets), i. One (1) tube of A and D ointment j. One (1) container of Diaderm rejuvenating foot cream (4oz. 1 container) During a resident interview on (MONTH) 28, (YEAR), at approximately 10:21 AM, Resident #78 was queried about self-administering medications. Resident #78 responded, Yes I have my own medications that I forgot to take this morning Resident #78 then self-administered the medications Vitron C, Calcium plus vitamin D and [MEDICATION NAME] eye drops. The resident further stated, When I call for medications that are going to help me. They do not have it or they take a long time to get it. Therefore, I buy what I need and take them. In response to how do get he over-the-counter medications, Resident #78 stated, When I go to Kaiser with my children I pick up what I need and they pay for it. According to the (MONTH) (YEAR) physician's orders [REDACTED]. (patient) has in her room, willing to take it by herself. Can keep in room with pt. A review of the (MONTH) (YEAR) Medication Administration Records (MAR) showed the physician order [REDACTED]. The clinical record lacked documented evidence the other over-the-counter medications were found documented for self-administration use or staff administration on the MAR. A review of care plan dated (MONTH) 21, (YEAR), showed Problem that read, Resident may keep Vitron C in her room for self-administration. The other over-the-counter medications found at bedside were not included in the care plan for Resident #. During a face-to-face interview with Employee # 17 on (MONTH) 28, (YEAR), at approximately 12:00 PM, Resident #78's self-medicating with several over-the-counter medications that were located in Resident #78's dresser drawer was discussed. Employee #17 stated, (resident name) self-administers own medication. We supervise (resident name) take the medication, (Resident name) will call when ready to take the medication. After reading the list of medications that the resident removed from the dresser drawer in the bedroom, Employee #17 acknowledged the findings. Also, the family was contacted and a meeting was scheduled for the next day. There clinical record lacked documented evidence the Interdisciplinary Care Team (IDT) determined that it was safe for Resident #78 to self-administer medications. Also, during the self-medication observation on (MONTH) 28, (YEAR) at approximately 10:22 AM, failed to demonstrate that the facility staff provided direct supervision of Resident #78 during self-administered of medications.",2020-09-01
26,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,241,D,0,1,BJXC11,"Based on observation and staff interview for one (1) of 40 sampled residents, the facility staff failed to promote one (1) resident's dignity when serving a lunch meal on (MONTH) 25, (YEAR). Resident# 222. The findings include: An observation on (MONTH) 25, (YEAR), at approximately 1:25 PM revealed Resident# 222 and Resident# 135 seated at same dining table. The facility staff served Resident#135 a lunch meal at 1:25 PM, Resident# 222 had not received a lunch meal. At approximately 1:40 PM, the facility staff was asked: why did Resident#222 not receive a lunch tray? Facility staff stated, the feeders are fed last. Facility staff served Resident# 222 a lunch meal at 1:40 PM. During a face-to-face meeting on (MONTH) 25, (YEAR), at approximately 2:00 PM, Employee # 17 and Employee# 18 acknowledged the findings.",2020-09-01
27,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,278,D,0,1,BJXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview for one (1) of 40 sampled residents, it was determined that facility staff failed to accurately code the Minimum Data Set (MDS) under Section B ( Vision) for (1) resident 's ability to see, in adequate light. Resident# 235. The findings include: On (MONTH) 30, (YEAR), at approximately 3:00 PM, a review of the medical record for Resident# 235, reveal resident admitted to the facility on (MONTH) 11, (YEAR), with an admitting [DIAGNOSES REDACTED]. Further review revealed a Minimum Data Set assessment dated (MONTH) 16, (YEAR). The assessment reveals the facility staff documented the number zero (0) in Section B1000 (Ability to see in adequate light with glasses or other visual appliances). This coding indicates the resident has Adequate Vision; sees fine detail such as regular print in newspapers/books. Further review of the Minimum Data Set assessment dated (MONTH) 16. (YEAR), Section I (Active Diagnoses) reveal the Resident ' s additional active [DIAGNOSES REDACTED]. The medical record lacked documented evidence that the MDS coding accurately reflects the resident's condition; [MEDICAL CONDITION]. During a face-to-face interview with Employee# 12 on (MONTH) 30, (YEAR), at approximately 3:00 PM, Employee # 12 acknowledged completing Section B1000 (Vision) and stated yes, he is blind.",2020-09-01
28,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,280,D,0,1,BJXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 40 sampled residents, it was determined that facility staff failed to update Resident 247's care plan to indicate that the resident no longer wore dentures. The findings include: During a dining observation on (MONTH) 1, (YEAR), at approximately 9:30 AM, Resident #247 was observed eating without natural teeth or dentures. When asked about difficulty chewing and eating, the resident stated, No. I had some dentures but I lost them when I went to the hospital. On (MONTH) 1, (YEAR) at 9:30 AM, a clinical record review showed a care plan for the use of dentures. The clinical record lacked documented evidence the facility staff updated the resident's care plan to reflect changes in the resident's oral status and lose of dentures. During a face-to-face interview with Employee #13 at approximately 10:30 AM on (MONTH) 5, (YEAR), the employee was asked about Resident #247's dentures. The Employee stated, The dentures were lost when the resident was hospitalized in (MONTH) and the daughter has not decided to replace them. He/she has a [DIAGNOSES REDACTED]. The employee acknowledged that the care plan was not updated to indicate that the resident no longer wears dentures.",2020-09-01
29,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,312,D,0,1,BJXC11,"Based on observation, record review, and resident and staff interview for one (1) of 40 sampled residents, the facility staff failed to provide routine oral care to one (1) totally dependent resident. Resident #154. The findings include: On (MONTH) 29, (YEAR), Resident #154 was observed with a right amputation above the elbow and left arm paralysis. A subsequent review of the clinical record showed Resident #154 was coded under Section G110 of the Minimum Data Set (MDS) as a four (4) which indicates that the resident is totally dependent on staff for all Activities of Daily Living (ADL). During a face-to-face interview with Resident #154 at approximately 11:30 AM on (MONTH) 29, (YEAR), the resident stated, I have a medical appointment on Thursday. I am going to see my doctor and I would like to have my teeth brushed before I go. The resident was asked whether his/her teeth are brushed when receiving bath in the mornings. Resident # 154 stated No, and I have an electric tooth brush plugged up by the bathroom sink but they (the Staff) do not use it. The Resident opened his mouth and displayed teeth covered with particles of food. This surveyor checked the bathroom and observed an electric toothbrush plugged into an outlet at the sink. The toothbrush was dry. On (MONTH) 30, (YEAR), at approximately 10:30 AM, upon a return visit to the resident's room to inquire whether his teeth were brushed and to determine if the toothbrush was used. The resident informed this writer that his teeth were not brushed. This writer checked the toothbrush and it was dry. Another observation made on (MONTH) 30, (YEAR) at approximately 2:45 PM, in the presence of Employee #5 showed that Resident #154's teeth were not brushed and a dry electric toothbrush in the bathroom. Employee #5 acknowledged that the staff failed to provide routine oral care to a resident who is totally dependent on them for all care needs.",2020-09-01
30,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,323,E,0,1,BJXC11,"Based on observation and interview, the facility staff failed to provide supervision for eight (8) residents observed in the Activity/Dining Room unattended for approximately 12 minutes. No employee was observed in the room. Residents #47, #59, 107, 121, 212, 219, 229, and 271. The findings include: On (MONTH) 29, (YEAR), at approximately 12:30 pm, eight (8) residents were observed in the second floor Dining Room waiting to be served their lunch. There were no facility staff present in the dining room at the time of the observation. This surveyor remained in the room 10 minutes before initiating the call light. The light was initiated in response to one (1) of the residents calling out for assistance. Two (2) Certified Nursing Assistants and one Registered Nurse (RN) responded to the light in approximately three to four minutes. The residents who were observed in the room were identified as: 1. Resident #47: A review of Section G of this resident's most recent quarterly MDS dated (MONTH) 02, (YEAR) revealed that the resident is coded as a four (4) Indicating that he/she is totally dependent on staff for all daily living activities. 2. Resident #59: A review of Section G of this resident's most recent quarterly MDS dated (MONTH) 26, (YEAR) revealed that the resident is coded as a three (3) is able to feed self with supervision but needs extensive assistance for all other daily living activities. 3. Resident #107: A review of Section G of this resident's admission MDS dated (MONTH) 20, (YEAR) revealed that the resident is coded as a three (3) and needs extensive assistance from two persons for all daily living activities. This resident fell and sustained a fracture prior to being admitted to the facility on (MONTH) 13, (YEAR). This resident was heard calling out, I want to pee. I don't want to wet myself. 4. Resident #121: A review of Section G of this resident's most recent quarterly MDS dated (MONTH) 08, (YEAR) revealed that he/she was coded as a three (3) and needed extensive assistance in mobility from one person and oversight and supervision for all other daily living activities. 5. Resident #212: A review of Section G of this resident's most recent quarterly MDS dated (MONTH) 03, (YEAR) revealed that this resident is coded as a three (3) and indicated that he/she needs extensive assistance with two or more persons' physical assistance for all daily living activities. 6. Resident #219: A review of section G of this resident's latest quarterly MDS dated (MONTH) 15, (YEAR) indicated that the resident was coded as a three (3) and needed extensive assistance from two (2) persons for transfer, mobility and dressing and needs supervision and oversight for eating. 7. Resident #229: A review of Section G of this resident's most recent quarterly MDS dated (MONTH) 12, (YEAR) revealed that this resident needed supervision/oversight for eating and was coded as a three (3) which indicated that the need for extensive assistance for all other activities of daily living exercises. This resident also has a history of falls as documented in the MDS. 8. Resident #271: A review of Section G of this resident's most recent quarterly MDS dated (MONTH) 16, (YEAR) revealed that this resident was coded as a three (3) and needs extensive assistance from two (2) persons for bed mobility and transfer and dressing. This resident also has a history of falls as documented in the MDS. Seven (7) of the eight (8) unsupervised residents needed extensive assistance from staff for their daily needs, one resident was totally dependent and three (3) residents have a history of falls. During a face-to-face interview with Employee #19 at approximately 1:00 PM, he employee was stated that a schedule is made daily and staff is assigned throughout the day for periods of 15 minutes each. The CNA who was scheduled to monitor the room/residents between 12:30 and 12:45 PM was attending to another resident but someone should have replaced (him/her) The employee acknowledged the finding.",2020-09-01
31,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,371,E,0,1,BJXC11,"Based on an observation made on (MONTH) 25, (YEAR), at approximately 9:00 AM, the facility failed to store food in a safe and sanitary manner in a large side-by-side refrigerator. The findings include: 1. On the second shelf of the refrigerator, several pieces of chicken observed immersed in liquid, covered with saran wrap and dated (MONTH) 22, (YEAR). 2. The following items stored on the shelf below the chicken were as follows: a. One (1) opened packet of hot dogs, dated (MONTH) 21, (YEAR), b. One (1) full packet of hot dogs undated and unlabeled; c. One (1) full packet of potatoes (French Fries) d. One (1) opened packet of French Fries (both undated and unlabeled) were all stored on the shelf below the chicken. 3. One (1) opened packet of bagels dated (MONTH) 18, (YEAR). 4. One (1) opened container of garlic butter no date. 5. One (1) container of mashed potato mix dated (MONTH) 01, (YEAR) 6. A container of chicken base dated (MONTH) 23, (YEAR). 7. A container of ground cinnamon dated (MONTH) 01, (YEAR). During a face-to-face interview with Employee #16 immediately after the observation, the employee stated that perishable items could be stored for three days after opening. The observations made in the presence of Employee #16 were acknowledged.",2020-09-01
32,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,456,D,0,1,BJXC11,"Based on observations made on (MONTH) 30, (YEAR), at approximately 10:40 AM, the facility failed to maintain essential equipment in good working condition as evidenced by one (1) of one (1) dishwashing machine that failed to maintain a minimum final rinse temperature of 180 degrees Fahrenheit during several consecutive wash cycles. The findings include: One (1) of one (1) dishwashing machine failed to reach and maintain a final rinse temperature of 180 degrees Fahrenheit on (MONTH) 30, (YEAR), at approximately 10:40 AM. During several, consecutive wash cycles, the final rinse temperature gauge was at or below 164 degrees Fahrenheit. A stack pump was added to the dishwashing machine by Ecolab at approximately 11:45 AM on (MONTH) 30, (YEAR), to circumvent low final rinse temperature issues and to enable the facility to use chlorine as a disinfectant. Dishes disinfection occurred after test strips confirmed that the disinfectant solution was at a minimum of 50 Parts per Million (PPM). The observations made in the presence of Employee #22 were acknowledged.",2020-09-01
33,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,463,D,0,1,BJXC11,"Based on observations, the facility failed to maintain call bells in good working condition as evidenced by defective call bells in two (2) of 28 resident's rooms. The findings include: During an observation at 10:40 AM, on (MONTH) 28, (YEAR), Resident #78 initiated his call light to request assistance with incontinence care. The facility staff responded after approximately 10 minutes to answer the call light. During a face-to-face interview with Employee#17 on (MONTH) 28, (YEAR), at approximately 1:00 PM regarding resident concerns of not getting the help he/she needed for toileting. The employee acknowledged the findings and reported, We had a problem with the call light, and we can hear the call light ring but have to check several rooms until we find which room is calling. We called Engineer found out the bulb was out. They presented the blown bulb to the surveyor. During a subsequent face-to-face interview with Employee #20 on (MONTH) 31, (YEAR), at approximately 11:00 AM. the employee stated that the visual indicator usually illuminates above the door of the resident room accompanied by a sound from the nurses' station when the call bell was activated. Employee #20 further added that when the call bells activate the visual indicator and the audible alarm should be seen and heard by staff, but the bulb was found to be out in the resident room. Employee #20 acknowledged the finding. 2. On (MONTH) 30, (YEAR), at approximately 3:30 PM, during tour two (2) of three (3) call bells in resident room #240 failed to alarm when initiated. The call bells were intended for use by bed B and c in Room #240. Employees #20 and 21 were present at the time of observations and acknowledged the findings.",2020-09-01
34,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2017-09-01,514,D,0,1,BJXC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the review of one (1) of 40 sampled resident, the facility failed to accurately transcribe a physician's telephone order for Resident #8. The findings include: A review of Resident #8's clinical record revealed a physician order [REDACTED]. change catheter monthly . On (MONTH) 19, (YEAR), review of the Treatment Administration Record (TAR) dated (MONTH) 1, (YEAR), revealed, a d/c (discontinue) foley catheter as a prescribed order. The clinical record lacked documented evidence that the physician wrote an order to discontinue the foley catheter. During a telephone interview with Employee #14 on (MONTH) 1, (YEAR), at 11:00 AM, the employee was questioned about the foley catheter order. Employee #14 stated, I did receive a verbal order to discontinue the Foley catheter and wrote in on the TAR, but forgot to write it on the physician order [REDACTED].>Employee # 2 acknowledged the findings after a record review at approximately 11:30 AM on (MONTH) 1, (YEAR).",2020-09-01
35,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,550,D,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for (1) one of 38 sampled residents facility staff failed to provide incontinent care in a dignified manner by leaving resident unattended and unclothed (exposed). Resident# 116 Findings included Resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 9/21/18 at 2:30 PM of the Annual Minimum Data Set ((MDS) dated [DATE] showed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) resident is scored as 0 which indicate resident is rarely/never understood. Section G (Functional Status) resident is coded as 4' totally dependent on staff for activities of daily living (dressing, toilet use, bathing, and personal hygiene). Observation on 9/21/18 at 2:00 PM showed Resident# 116 lying in bed exposed with privacy curtain partially drawn. Employee# 22 entered the room holding towels and stated I just left for a minute I am changing her diaper, I should have covered her (resident) up, I am sorry. During an interview on 9/21/18 at 2:00 PM Employee# 13, Nursing Supervisor, stated yes, I see the resident, this is a problem I will take care of it. Review of the nursing care plan, a problem start date of 2/9/18 Resident has potential for skin breakdown due to her being incontinent of bowel and bladder; Approach: Maintain resident's dignity and privacy when providing care. Facility staff failed to provide incontinent care with dignity by leaving resident unclothed (exposed) and vulnerable. During a face-to-face interview at the time of the observation on 9/21/18 at 2:00 PM, Employees #13 and #22 acknowledged the finding.",2020-09-01
36,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,558,D,0,1,PSFH11,"Based on observation, staff, resident and a family member Interviews for one (1) of 38 sampled residents, facility failed to provide the resident with a replacement television and to place the television in an appropriate position where it can be viewed by the resident. Resident #202. Findings included . As reported to this surveyor on (MONTH) 20, (YEAR) at approximately 2:30 PM the resident has a very small television (approximately 13 - 15 inches) which sits on the side of the bed and which she is not able to view when she is in bed. The informant further reported that the resident had a larger television (19 inches) which was purchased by the family when she was first admitted to the facility. According to the informant the original television was accidentally destroyed while an employee was cleaning the resident's room. He could not recollect the date of the incident but he thinks it was a few years ago. The resident was admitted to the facility on (MONTH) 16, 2007. The admission inventory sheet showed a 19 inch television among the resident's list of possessions. An observation of the room on (MONTH) 20, (YEAR) showed A 13 - 15 inch television on a portable tray (television tray) at the side of the resident's bed. The position of the television did not allow the resident to watch the television while lying in bed. After the observation the resident was asked if she liked her television and its location. She responded that it was too small and that she could not watch when she was lying in bed. A face-to-face interview was conducted with Employee #8 at approximately 2:30 PM on (MONTH) 24, (YEAR). During the interview I advised the employee of the informant's concern about the situation but would investigate and inform me of the results of her investigation. During a follow-up face-to-face interview at approximately 11:00 AM on (MONTH) 25, (YEAR) the manager stated she was informed that replacement of items are based on original value less depreciation; hence, the reason the resident's 19 inch television was replaced with a 13 inch television. She added that the value of the current television was equal to the value of the television that was destroyed. The manager also added that in order for the television to be mounted on the wall the family would need to bring in the materials (brackets, bolts, screws etcetera). During another face-to-face interview with Employee #1 the employee acknowledged that the facility failed to provide the resident with an appropriate replacement television. However, the employee stated that he was not aware of the situation but now that he is aware he will ensure that the resident receives an appropriate replacement television and that it is in a location that will be satisfactory to the resident and the family.",2020-09-01
37,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,575,E,0,1,PSFH11,"Based on observation, document review and staff interview, the facility failed to ensure the accuracy of the contact information to include the names, mailing and email addresses for all pertinent State agencies and advocacy groups posted and failed to ensure the posting included a statement that the resident may file a complaint with the State Survey Agency was posted in an accessible and understandable manner. The resident census was 240 on the first day of survey. Findings included . During tour of the facility on 9/26/18 at 12:00 PM, the Important Contact Numbers sign was observed posted on the wall behind the nurses' station in small print. The Important Contact Numbers signage contained telephone numbers to report grievances to the following organization: the facility administrator, Department of Consumer and Complaint/Incident Hotline number, Regulatory Affairs, District Ombudsman, and District of Columbia Office of Aging. However, the signage failed to display the correct names and titles of the administrators for the aforementioned organizations. Further inspection of the required posting showed that the font size of the print was very small and not easily seen by individuals in wheelchairs. The facility failed to ensure the posting accurately reflected all State agencies information to include mailing and email addresses, in a font size that is accessible and understandable by individuals in wheelchairs. During a face to face interview on 9/26/18 at 3:00 PM, Employee #10, was shown the required posting of contact information. Employee #10 was in agreement that the font size was too small further stated that corrections would be made to the sign and move to a lower location so it can could be seen by individuals in wheelchairs. During a face-to-face interview at the time of the observation Employee #10 acknowledged the findings.",2020-09-01
38,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,577,E,0,1,PSFH11,"Based on observation, document review and staff interview, the facility staff failed to ensure the most recent Federal State Survey results and plan of correction was available for review by residents and family members on Unit 1st floor (Orange). The resident census was 240 on the first day of the survey. Findings included . During tour of the facility on 9/26/18 at 12:00 PM, an observation showed a white binder located at the nursing station with green and white signage Survey Book please do not remove survey book from this area, request additional copies from Administration, Thank You. A further review of the binder showed Statement of Deficiencies (CMS2567) and Plan of Correction dated 11/19/14. During an interview on 9/26/18 at 12:30 PM, Employee#10 stated, this need to be updated I will put last year's CMS2567 in the survey book. During a face-to-face interview Employee#10 acknowledged the finding at the time of the observation.",2020-09-01
39,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,584,E,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview the facility failed to provide housekeeping and maintenance services necessary to maintain a comfortable interior as evidenced by: one (1) of one (1) clogged sink; soiled floors were observed in one (1) of one (1) the electrical closet, one (1) of one (1) pantry and one (1) of one (1) clean linen room; soiled ceiling tiles in one (1) of one (1) panty and one (1) of nine (9) dayrooms; floor tile damaged near the ice machine in one (1) of one (1) pantry; antiskid strips were not secure in two (2) of two (2) resident bathrooms; urine odor in two (2) of two (2) resident bathrooms and a damaged wall in one (1) of 38 resident rooms. Findings included . During observations on the first floor, second floor and third floors on (MONTH) 26, (YEAR), between 4:00 PM and 7:30 PM, resident rooms and common areas were observed with the following: 3 green toilet training bathroom had a clogged sink in one (1) of one (1) observed Floors soiled with dust in the electrical closet C332D the storage room C333A, areas of the baseboard located in the dayroom where recessed in one (1) of one (1) observed 3 blue pantry floor was soled beside and behind the ice machine with dust in one (1) nine (9) observed 3 orange clean linen room floor surface was soiled and had paper on the floor in one (1) on nine (9) observed 2 orange 287 dayroom ceiling tile stained in one (1) nine (9) observed 2 orange pantry ceiling tiles stained in one (1) nine (9) observed 3 blue pantry floor tile damaged near the ice machine in one (1) nine (9) observed rooms [ROOM NUMBERS] had a urine odor in the resident's bathroom in two (2) of 38 resident bathrooms 3 orange shower room C340 antiskid strips were not secure and the antiskid strips were not secure in toilet room A393C in two (2) of two (2) observed Damaged wall on 3green room [ROOM NUMBER] residents room in one (1) of 38 resident rooms. During a face-to-face interview on (MONTH) 26, (YEAR), at the time of the observations, Employee #4 confirmed the findings.",2020-09-01
40,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,656,D,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, and staff interview, the facility failed to develop and implement an individualized care plan to meet the needs of the resident in two (2) of 38 resident records reviewed (Residents' #167 and 108). Findings included . [NAME] Resident #167 was admitted with a past medical history including Dementia. Review of the Minimum Data Set ((MDS) dated [DATE] showed Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive deficit. The surveyor conducted a tour of unit 2 Orange on 09/19/18 at approximately 10:00AM. During the observation Resident #167 was observed seated in a wheelchair in her room facing the hallway. The surveyor conducted another tour on 09/20/18 at approximately 11:00 AM. Resident #167 was again observed seated in a wheelchair in her room, facing the hallway. Later on the in the afternoon at approximately 2:00 PM, the Resident was seen sleeping in her bed. On 09/25/18 at approximately 11:30AM, Resident #167 was again seen seated in her wheelchair, facing the hallway. Review of section F of the MDS dated [DATE], showed that listening to music and participating in her favorite activities, is very important. Doing things with groups of people and going outside to get fresh air while the weather is good, is somewhat important. Review of the Activities care plan for Resident #167, last reviewed on 05/08/18 shows that the resident prefers activities that identify with her prior lifestyle. The goal is that the Resident will express satisfaction with her daily routine and leisure activities. However, the activity preferences are not listed, and the approaches are not individualized to meet the needs of the resident. The surveyor conducted a face to face interview on 09/25/18 at 12:06 PM with Employee #11, Nurse Manager for 2 Orange, regarding the Activity plan for Resident #167. She stated that Resident #167 is non-compliant with leaving her room and from time to time the Activities staff will come by to visit her. The facility failed to develop a care plan was individualized with goals and approaches to meet the needs of the resident. The surveyor conducted a face to face interview on 09/25/18 at 12:30 PM with Employee #11, and 25, and they acknowledged the findings. B. Resident #108 was admitted with a past medical history of [REDACTED]. She was admitted to 1 Blue, a locked unit designated Dementia unit. Review of the care plan that addresses her Alzheimer's/Dementia, last edited 07/17/18 showed a goal that the Resident will be reoriented to person, place and time and resident will be safe in their environment of the next 90 days.The approaches documented were: 1. Reorient resident to person, place and time as needed when confusion is noted. 2. Monitor residents whereabout in the facility to ensure safe environment. 3. Remove resident from areas where there is over stimulation that agitated or confuses resident. 4. Document declines in cognitive status in the clinical record. 5. Administer medications as ordered by MD (Medical Doctor) 6. Psych (psychiatric) evaluations as needed. The facility failed to develop an individualized person-centered care plan with goals and approaches to meet the needs of the resident. The surveyor conducted a face to face interview on 09/24/18 at 1:00 PM with Employee #26, Assistant Nurse Manager of 1 Blue. He acknowledged the findings.",2020-09-01
41,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,679,D,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview one (1) of 38 sampled residents, the facility failed to ensure that activities met the need of Resident #167. Findings included . Resident #167 was admitted with a past medical history including Dementia. Review of the Minimum Data Set ((MDS) dated [DATE] showed Brief Interview for Mental Status (BIMS) score of 1, indicating severe cognitive deficit. The surveyor conducted a tour of unit 2 Orange on 09/19/18 at approximately 10:00AM. During the observation Resident #167 was observed seated in a wheelchair in her room facing the hallway. The surveyor conducted another tour on 09/20/18 at approximately 11:00 AM. Resident #167 was again observed seated in a wheelchair in her room, facing the hallway. Later on the in the afternoon at approximately 2:00 PM, the Resident was seen sleeping in her bed. On 09/25/18 at approximately 11:30AM, Resident #167 was again seen seated in her wheelchair, facing the hallway. Review of section F of the MDS dated [DATE], showed that listening to music and participating in her favorite activities, is very important. Doing things with groups of people and going outside to get fresh air while the weather is good, is somewhat important. Review of the Activities care plan for Resident #167, last reviewed on 05/08/18 shows that the resident prefers activities that identify with her prior lifestyle. The goal is that the Resident will express satisfaction with her daily routine and leisure activities. However, the activity preferences are not listed, and the approaches are not individualized to meet the needs of the resident. The surveyor conducted a face to face interview on 09/25/18 at 12:06 PM with Employee #11, Nurse Manager for 2 Orange, regarding the Activity plan for Resident #167. She stated that Resident #167 is non-compliant with leaving her room and from time to time the Activities staff will come by to visit her. The facility failed to provide activities to meet the needs and preferences of Resident #167. The surveyor conducted a face to face interview on 09/25/18 at 12:30 PM with Employee #11, and 25, Registered Nurse. The acknowledged the findings.",2020-09-01
42,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,684,D,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview of one (1) of 38 sampled residents, the facility staff failed to instruct resident proper administration of medication according to professional standards of practice and manufacturer's specification for one (1) of one resident receiving nasal spray. (Resident # 65) Finding included . The facility staff failed to follow professional standards of practice and manufacturers specification for administering [MEDICATION NAME] nasal spray (indicated for the management of the nasal symptoms of [MEDICATION NAME] nonallergic rhinitis in adult and pediatric patients aged 4 years and older) during medication administration observation for Resident #65. Resident #65 was admitted to the facility on (MONTH) 3, 2013, with [DIAGNOSES REDACTED]. On (MONTH) 20, (YEAR) at approximately 10:15 AM, the surveyor observed Employee #20 handed Resident #65 the [MEDICATION NAME] nasal spray. Resident #65 self-administered [MEDICATION NAME] one spray per nostril. Employee #20 instructed the resident to administer a second dose. The resident administered a second dose of [MEDICATION NAME], one spray per nostril. Employee #20, returned the [MEDICATION NAME] to the medication cart. A review of the physician's orders [REDACTED]. A face-to face interview conducted on (MONTH) 20, (YEAR) at approximately 10:30 AM, Resident #65 stated she could take her own medication. Manufacturer instructions stated the resident should first blow your nose; close one (1) nostril; tilt your head forward slightly; start to breathe in through your nose, and while breathing, press firmly and quickly down one (1) time on the applicator to release the spray; then breathe out through your mouth. If a second spray is required in that nostril, repeat the process. The medication administration observation failed to support that the resident self-administered the nasal spray in accordance with manufacturer's recommendation to ensure adequate delivery of dose. Furthermore, the facility staff did not provide guidance while observing the resident's self-administration of medication. https://www.rxlist.com/[MEDICATION NAME]-d6rug.htm#medguideI A face-to-face interview conducted on (MONTH) 20, (YEAR), at approximately 10:45 AM, Employees' # 20 and #15 acknowledged the findings.",2020-09-01
43,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,689,D,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 38 sampled residents facility staff failed to provide care in accordance with physicians' order and professional standards of care as evidenced by a resident fall. Resident # 33. Findings included . Facility staff failed to maintain safety to prevent a resident fall by failing to raise the bed side rails when providing incontinent care. Resident # 33 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 9/24/18 at 10:00 AM of the Quarterly Minimum Data Set ((MDS) dated [DATE] showed Section C (Cognitive Patterns) Brief Interview for Mental Status (BIMS) resident is scored as 0 which indicate resident is rarely/never understood. Section G (Functional Status) resident is coded as 4' totally dependent on staff for activities of daily living (dressing, toilet use, bathing, and personal hygiene). Section H (Bladder and Bowel) Resident is coded as 3 which indicate, always incontinent of bladder and bowel. Section J (Health Conditions) J1700 Fall History on Admission/Entry or Reentry is coded as 1 which indicate resident had a fall during the last month; J1900 Number of Falls since Admission/Entry or Reentry Prior Assessment is coded as 1 No injury (no evidence of any injury is noted on physical assessment by the nurse or primary care clinician). Review of the nursing care plan showed Resident at risk for falling; approaches assess resident frequently to assure that resident is positioned correctly on the bed, keep call light in reach at all times, observe frequently and place in supervised area when out of bed, provide incontinent care as needed. Review of the physician order [REDACTED]. On 9/24/18 at 11:30 AM a review of the nurses note dated 5/3/18 showed Resident has fallen while the Certified Nursing Assistant (CNA) and family member were changing the resident, CNA rolled the resident to her side, and she (resident) had fallen to the floor, there were no visible injuries, and the CNA stated the position of the side rails was down, the CNA was provided education that the side rails must be up when providing care. On 9/24/18 at 1:00PM observed resident lying quietly in bed and the 1/2 side rails were raised, secured to the bed and functioning as intended. During an interview with Employee#15, yes, I am aware of the resident's fall but there was no injury. During an interview on 9/24/18 at 1:30 PM Employee#24 stated I received training on safety precautions to prevent falls, it takes two staff to provide incontinent care I should have asked staff for help and put the side rails up. During an interview on 9/24/18 at 4:00 PM, Employee# 23 stated I was here and Employee #24, CNA called for help I met the resident on the floor, there were no visible injuries, we got the resident on the bed and sent her (resident) to (hospital name). During an interview with Employee#15, yes, I am aware of the resident's fall but there was no injury. A review of the medical record showed on resident was transferred to (Hospital name). A further review of the medical record showed resident did not sustain an injury following the fall (5/3/18). Facility staff failed to maintain safety to prevent a resident fall by failing to raise the bed side rails when providing incontinent care. During a face-to-face interview on 9/24/18 at 5:00 PM Employee #15 acknowledged the finding.",2020-09-01
44,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,690,D,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff and resident interview of one (1) of 38 sampled residents, the nursing staff failed to evaluate and address catheter care for a resident with an indwelling catheter and recurrent urinary tract infections (Resident #197). Findings include . The[NAME]Center for Aging Services policy entitled Catheter Care - Suprapubic, undated, stipulates that the purpose of catheter care is to reduce infection and promote good hygiene. The procedure of catheter care included .cleanse the skin around the catheter and the entire visible length of the catheter with soap and water. Be sure all drainage is removed from skin and catheter . The policy describes that the type and amount of drainage should be noted, if present. Resident #197 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the medical record showed that Resident #197 had multiple urinary tract infections (UTI's) beginning in 03/2017 when he was placed on isolation for an Extended Spectrum Beta-Lactamase (ESBL) infection in the urine. Additionally, he was treated for [REDACTED]. Review of the physician orders [REDACTED]. The surveyor conducted a face to face interview with Employee #25, Charge Nurse, 2 Orange, in the presence of Employee #11, Unit Manager 2 Orange, on 09/25/18 at 11:08 AM regarding catheter care. When asked what the procedure was for catheter care, she stated that the nurse observes the drainage bag and checks the urine for sediment, color, and blood. When the surveyor asked if cleaning the catheter was considered catheter care, she stated no, cleaning the catheter is considered an Activity of Daily Living (ADL) and is performed by the Certified Nursing Assistant (CNA). When asked how the resident's frequent UTI's were being addressed related to catheter care, she could offer no further insight. The surveyor conducted a face to face interview on 09/26/18 at 2:45 PM with Employee #27, Infection Control Nurse Practitioner, in the presence of Employee # 1, Administrator, and Employee 28, Infection Preventionist, regarding how the Infection Control department was addressing the recurrent Catheter Acquired Urinary Tract Infections (CAUTI's) for Resident #197. She stated that they provided education for staff regarding hand hygiene. When asked if training was provided to staff regarding catheter care, she stated no. The above employees acknowledged the findings.",2020-09-01
45,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,744,D,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, personnel training record and staff interview of one (1) of 38 sampled residents, the facility failed to develop a Dementia Care Program and ensure the competency of staff, to address the needs of residents diagnosed with [REDACTED].#108) Findings included . Resident #108 was admitted with a past medical history of [REDACTED]. She was admitted to 1 Blue, a locked unit designated Dementia unit. Review of the care plan that addresses her Alzheimer's/Dementia, last edited 07/17/18 showed a goal that the Resident will be reoriented to person, place and time and resident will be safe in their environment of the next 90 days.The approaches documented were: 1. Reorient resident to person, place and time as needed when confusion is noted. 2. Monitor residents whereabout in the facility to ensure safe environment. 3. Remove resident from areas where there is over stimulation that agitated or confuses resident. 4. Document declines in cognitive status in the clinical record. 5. Administer medications as ordered by MD (Medical Doctor) 6. Psych (psychiatric) evaluations as needed. During a tour of unit 1 Blue, conducted on 09/24/18 at 2:20 PM, the surveyor observed two Certified Nursing Assistants (CNA) throwing a beach ball to Residents seated in the day room. The surveyor conducted a face to face interview on 9/24/18 at approximately 2:30 PM with Employee # 29, Certified Nursing Assistant, regarding training she received on dementia care. She stated that she has not had any formal training. The surveyor conducted a face to face interview on 09/24/18 at 2:45 PM, with Employee #30, Certified Nursing Assistant regarding Dementia training. She stated that the staff was sent offsite to complete training. Review of Continuing Education Unit (CEU) certificates for staff showed that Employee #30 completed six hours of training on [MEDICAL CONDITION] and Dementia Care. Employee #29, did not complete training. The facility failed to develop a Dementia Care program to meet the needs of residents housed on a Dementia Care unit. The surveyor conducted a face to face interview on 09/26/18 at 9:21 AM with Employees #3, Director of Clinical Operations, and Employee #1, Administrator. Both acknowledged that the facility had no formal Dementia Care Program at the time of survey.",2020-09-01
46,WASHINGTON CTR FOR AGING SVCS,95014,2601 18TH STREET NE,WASHINGTON,DC,20018,2018-09-26,842,D,0,1,PSFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 38 sampled residents facility staff failed to accurately document a fall assessment to reflect the resident's current status. Resident# 33. Findings included . Resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review on 9/22/18 at 1:00 PM of the Quarterly Minimum Data Set (MDS) showed Section G0400 (Functional Limitation Range of Motion) lower extremity (hip, ankle, knee, foot) impairment on both sides; G0600 (Mobility Devices) wheelchair is selected as normally used. A review of the physician note (Initial or Progress) dated 7/13/18 showed Dementia-Advanced, Hypertension, [MEDICAL CONDITION], Bilateral Above Knee Amputation, Resident with multiple problems, completely dependent for all activities of daily living, she (Resident) did have a reported fall in (MONTH) with no injuries. Review of the care plan showed Resident is limited in physical mobility related to bilateral above the knee amputation. Review of the Fall assessment dated [DATE] showed Description: Fall Risk, Ambulation/Elimination Status is scored as 4 which indicates resident is ambulatory/incontinent. Fall Risk Score-Score of 10 or higher represents a high risk for falls. The Fall Risk is scored as 13.0 which represents a high risk for falls. During an interview 9/22/18 on at 2:00 PM Employee# 15 stated this score is not correct, the resident has a bilateral amputation and is not ambulatory. Facility staff failed to accurately calculate the Fall Risk Score and code the Fall Risk Assessment to reflect the resident's current status as a bilateral [MEDICAL CONDITION]. During a face-to-face meeting on 9/22/18 at 3:00 PM Employee# 15 acknowledged the finding.",2020-09-01
47,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2019-03-27,561,D,1,0,60IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff and resident interviews for one (1) of four (4) residents, it was determined that facility staff failed to respect Resident #1's request to remain in bed. The findings include: Resident #1 was admitted to the facility on (MONTH) 15, 2013. According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 19, (YEAR), Resident #1 scored 12/15 on the Brief Mental Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page -14, a score of 8-12 suggests that the resident has moderately impaired cognitive skills for daily decision making. Resident #1 was assessed as requiring supervision for eating, extensive assistance for bed mobility, transfers, dressing and totally dependent for personal hygiene, toilet use and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse's note dated (MONTH) 3, (YEAR) at 16:38 (4:38 PM): (Resident#1) met his/her goal of improving his/her strength to be out of bed, and maintaining his/her flexibility, but still requires lots of encouragement. Will monitor for needed intervention as needed. A telephone interview was conducted with Employee #1on (MONTH) 21, 2019 at 2:00 PM: I washed him/her up and got him dressed and he/she asked me to let him/her stay in bed. I said okay and got him/her all cleaned up and left him/her in bed. About eleven o'clock the charge nurse said to get (Resident #1) up to weigh him/her. I was transferring (Resident #1) to the wheelchair and he/she scratched me on my neck. He/she didn't want to get up out of bed and I had promised him/her I wouldn't get him/her up. But the charge nurse and the dietician told me I had to get him/her up. (Resident #1) was a very easy transfer with one person if he/she cooperates. When he/she doesn't want to do anything he/she will fight and scratch . Employee #1 wrote and signed the following statement dated (MONTH) 5, (YEAR): I, (Employee #1) had the 1st group. I was doing my AM care to (Resident #1). I promised him/her I will not bring him/her out of bed before he/she allows me to take care of him/her. I wash him/her and shave him/her then dress him/her up in the bed. I fulfill the promise I made to him/her around three hours. My nurse told me to bring him/her out for weigh him/her. I went to bring him/her out of bed. I put him/her in sitting position to put him/her in his/her chair (wheelchair). He/she start fighting me and scratch me at my neck. To prevent him/her from falling I quickly put him/her in his chair (wheelchair). I said to him/her don't do that again. See you scratched my neck. With angry voice the lady (Employee #3) at the door asked me What is it? I told him/her he/she scratched my neck when putting him/her in his/her chair. I learn my voice was high when I said Don't do that with anger of pain at my neck. I hold him/her and say Don't scratch people. I do not hit him/her that is all what happened. Resident #1 requested to remain in bed. Employee #1 had agreed to that request. Employee #1 was directed to get Resident #1 out of bed, against his/her wishes at the direction of the charge nurse. There was no evidence that Employee #1 relayed Resident #1's request to remain in bed to the charge nurse. Facility staff failed to respect Resident #1's request to remain in bed. A face-to-face interview was conducted with Employee #2 on (MONTH) 4, 2019 at 9:30 AM, who acknowledged the above.",2020-09-01
48,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2019-03-27,657,D,1,0,60IX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff and resident interviews and record review for one (1) of four (4) residents, it was determined that facility staff failed to update the care plan to reflect the MDS assessment in (MONTH) (YEAR) and (MONTH) 2019 that the resident required a two person assist with transfers. Resident #1 The findings include: Resident #1 was admitted to the facility on (MONTH) 15, 2013. According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 19, (YEAR), Resident #1 scored 12/15 on the Brief Mental Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page -14, a score of 8-12 suggests that the resident has moderately impaired cognitive skills for daily decision making. Resident #1 was assessed as requiring supervision for eating, extensive assistance for bed mobility, transfers, dressing and totally dependent for personal hygiene, toilet use and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to the MDS with a target date of (MONTH) 18, 2019 and (MONTH) 19, (YEAR), Section/Item GO11B2 - Transfer support provided was coded as 3 - two person physical assist. A care plan meeting was held on (MONTH) 22, (YEAR). According to the resident's care plan, under Focused: The resident has and ADL Self Care Performance Deficit related to impaired mobility with a date initiated 06/17/2015: Transfer: The resident has requires (1) staff participation with transfers with date initiated 10/22/2015. On the second page of the same Focus under Interventions: Transfer: The resident requires total assistance with transfers with and initiation date of 10/22/2015. A telephone interview was conducted with Employee #1 on (MONTH) 21, 2019 at 2:00 PM. He/she stated, (Resident #1) was a very easy transfer with one person if he/she cooperates. When he/she doesn't want to do anything he/she will fight and scratch. I have been working here with Resident #1 since (YEAR). I have always transferred Resident #1 by myself. A face-to--face interview was conducted with Employee #2 on (MONTH) 4, 2019 at 9:30 AM, who acknowledged that Resident#1's care plan was not updated to reflect the MDS assessment that a two person transfer was required. The record was reviewed (MONTH) 4, 2019.",2020-09-01
49,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,253,E,0,1,R92T11,"Based on observations made on (MONTH) 23, (YEAR), at approximately 10:00 AM, it was determined that the facility failed to maintain resident's environment in proper working condition as evidenced by dusty exhaust vents in 12 of 34 resident's rooms, a lack of hot water from one (1) of five (5) shower stalls on the second floor, missing call bell pull cords from one (1) of five (5) shower stalls on the second floor and one (1) of 34 residents rooms, missing overhead light pull strings from three (3) of 34 resident's rooms, burnt out light bulbs in three (3) of 34 resident's rooms, soiled bathroom floors in two (2) of 34 resident's rooms, marred walls in three (3) of 34 resident's rooms, a foul odor in two (2) of 34 resident's rooms and clutter in two (2) of 34 resident's rooms. The findings include: 1. Exhaust vents soiled with dust in 12 of 34 resident's rooms including Rooms #326, 324, 314, 243, 227, 226, 225, 210, 207, 141, 139, and 113. 2. No hot water available in one (1) of five (5) shower stalls located in the shower room on the second floor. 3. The call bell pull cord for one (1) of five (5) call bells located in the shower room on the third floor and one of 34 resident's rooms (#346) was missing. 4. The pull-string from the overhead light in three (3) of 34 resident's rooms was missing (Rooms #346, 214, and 127). 5. The top lightbulb from the overhead light fixture in three (3) of 34 resident's rooms did not illuminate when tested (Rooms 207, 210B, and 243A). 6. The bathroom floor in two (2) of 34 resident's rooms soiled with many stains (Rooms #225 and 227). 7. Walls marred in three (3) of 34 resident's rooms including rooms #207, 226, 330. 8. Offensive, foul odor evident in two (2) of 34 resident's rooms (Rooms #225 and 230). 9. Two (2) of 34 residents' rooms cluttered with many bags, boxes, straws, napkins, sodas and juice (Rooms #240 and 326). The observations made, in the presence of Employee #14 or Employee #15, were acknowledged.",2020-09-01
50,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,278,D,0,1,R92T11,"Based on observation, record review, staff and resident interviews for one (1) of 29 stage 2 sampled residents, it was determined that facility staff failed to accurately code the Minimum Data Set (MDS) for the use of corrective lenses under Section B (Hearing, Speech, and Vision) for Resident #144. The findings include: Facility staff failed to code the MDS for Resident #144's use of corrective lenses. A face-to-face interview with Resident #144 occurred on (MONTH) 20, (YEAR), in the resident's room at approximately 2:30 pm, in the presence of Employee #8. The resident was observed wearing eyeglasses. On (MONTH) 20, (YEAR), a medical record review revealed Minimum Data Set assessments dated (MONTH) 31, (YEAR), and (MONTH) 27, (YEAR). The assessments revealed the facility staff documented the numeral two (2) in Section B1000 (Ability to see in adequate light with glasses or other visual appliances). This coding indicates the resident has Moderately impaired-limited vision; not able to see newspaper headlines but can identify objects. Also, Section (B1200) Corrective Lenses (contacts, glasses or magnifying glass) was coded as 0 indicating the resident does not wear glasses. Further review of the Edit Note Section revealed documentation which indicated that Resident #144 has glasses on at all times when asked if they helped with reading the resident responded, no. The medical record lacked documented evidence that the MDS was code to accurately reflect the resident's condition. During a face-to-face discussion with Employee #10 on (MONTH) 20, (YEAR), Employee #10 acknowledged writing the information in the Edit Note section and completion of Section B1000 and B1200.",2020-09-01
51,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,279,D,0,1,R92T11,"Based on observations, record review, and staff interview for one (1) of 29 stage 2 sampled residents, it was determined that facility staff failed to develop a care plan with appropriate goals and objectives to address visual impairment for Resident #223. The findings include: On (MONTH) 26, (YEAR), at 11:00 AM, a review of an admission MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of (MONTH) 01, (YEAR), revealed Resident #223, was coded under Section B (Vision) as Impaired- sees large print, but not regular print in newspapers/books. The clinical record lacked evidence of the development of a care plan with goals and approaches to address the resident's visual impairment. During a face-to-face interview conducted on (MONTH) 26, (YEAR), at approximately 12:00 PM, Employee #8 acknowledged the findings.",2020-09-01
52,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,309,D,0,1,R92T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 29 sampled residents, it was determined that facility staff failed to assess the blood pressure (B/P) before administering one (1) resident's antihypertensive medication ([MEDICATION NAME]) (Resident #169.) The findings include: On (MONTH) 20, (YEAR), at 9:52 AM, during a medication administration observation, Employee #5 was observed administering [MEDICATION NAME] (antihypertensive medication) tablet 10 mg to Resident #169. Before administering the [MEDICATION NAME], the employee failed to assess the resident's B/P. A medical record on (MONTH) 20, (YEAR) revealed a physician's orders [REDACTED]. Hold if SBP During a face-to-face interview conducted with Employee #5, immediately after the administering of the [MEDICATION NAME], the surveyor asked the employee the rationale for the lack of assessment of the resident's B/P. Employee# 5 responded, I meant to take it, but I forgot. I was nervous because you were watching me. The employee assessed the resident's blood pressure which revealed a reading of 141/98. Employee# 5 acknowledged the findings.",2020-09-01
53,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,371,E,0,1,R92T11,"Based on observations made on (MONTH) 20, (YEAR) at approximately 10:00 AM, it was determined that the facility failed to prepare and serve foods under sanitary conditions as evidenced by two (2) of four (4) soiled convection ovens, one (1) of one (1) soiled grease fryer, four (4) of four (4) soiled steam table covers, two (2) of eight soiled salad dressing containers and two (2) of two (2) drain pipes that extended into the floor drain. The findings include: 1. Two (2) of four (4) convection ovens soiled at the bottom. 2. The side panels to one (1) of one (1) grease fryer soiled with grease deposits. 3. Four (4) of four (4) steam table covers soiled and discolored. 4. A one-gallon plastic container of Ranch dressing and a one-gallon plastic container of Ceasar dressing stored in the walk-in refrigerator soiled on the outside with leftover residue. 5. Drain pipes from the tilt skillet and the steamers extended too far into the floor drain. The observations made in the presence of Employee #12 or Employee #13 were acknowledged.",2020-09-01
54,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,372,D,0,1,R92T11,"Based on observations made on (MONTH) 20, (YEAR), at approximately 10:00 AM, it was determined that the facility failed to dispose of garbage in a sanitary manner as evidenced by loose trash bags improperly stored, on the ground beside the trash bins. The findings include: Loose items such as empty cans, paper and two (2) full trash bags were observed on the ground, next to the trash bins located outside the facility. The observation made, in the presence of Employee #13, were acknowledged.",2020-09-01
55,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,431,D,0,1,R92T11,"Based on record review and staff interview, it was determined the facility staff failed to ensure that medication refrigerator temperatures were recorded every night on two (2) of three (3) nursing units. The findings include: Facility staff failed to ensure that the medication refrigerators temperature were consistently recorded every night on two (2) of three (3) nursing units (Units #2 and 3). On (MONTH) 26, (YEAR), between the hours of 9:00 AM and 11:00 AM, a review of the Medication Temperature Logs revealed the nursing staff did not consistently record refrigerator temperatures on Nursing Units #2 and 3. The missing dates are as follows: Nursing Unit 2 March 14, (YEAR) March 15, (YEAR) May 16, (YEAR) June 10, (YEAR) Nursing Unit 3 June 23, (YEAR) June 24, (YEAR) Employees #4 and 9 acknowledged the findings at the time of the review.",2020-09-01
56,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,456,D,0,1,R92T11,"Based on observation and staff interview for one (1) of 29 sampled Stage 2 residents, it was determiend the facility staff used an unauthorized blood pressure cuff (one brought from the employee's home) to assess the resident's blood pressure (Resident #169). The findings include: On (MONTH) 20, (YEAR), at approximately 10:00 AM, Employee #5 was observed assessing Resident #169's Blood Pressure (B/P) using a (Store Brand), wrist monitor. No model (name) was discernable on the monitor. Upon completion of the blood pressure assessment, the surveyor asked Employee #5 where he/she had obtained the B/P monitoring device. The employee responded, I brought it from home. The employee further explained the equipment was brought from home and approval had not been given by the facility for its use. There was no evidence the blood pressure monitor used by staff was cleared by the facility's biomedical department/contractor to ensure its accuracy. During a face-to-face interview with Employee #2 at approximately 2:00 PM on (MONTH) 20, (YEAR), the employee stated that employees are not permitted to use personal equipment not approved by the facility. The observation shared with Employee #2 was discussed and acknowledged.",2020-09-01
57,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2017-06-27,514,D,0,1,R92T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 29 Stage 2 sampled residents, it was determined that facility staff failed to consistently and accurately document that one (1) resident received his/her [MEDICATION NAME] medication for pain on the MAR (Medication Administration Record) (Resident #201). The findings include: A review of the Medical Record on (MONTH) 27, (YEAR), at 10:00 AM revealed the following: The (MONTH) (YEAR) physician's orders [REDACTED]. The Controlled Medication Utilization Record revealed the following: May 7, (YEAR), [MEDICATION NAME] 5mg was signed as given at 9:00 AM and 5:00 PM May 9, (YEAR), [MEDICATION NAME] 5mg was signed as given at 9:00 AM and 9:45 PM May 10, (YEAR), [MEDICATION NAME] was signed as given at 9:00 PM, 4:00 PM and 10:00 PM A subsequent review of the MAR indicated [REDACTED]. During a face-to-face interview conducted with Employee #2, on (MONTH) 27, (YEAR), at approximately 11:30 AM, the employee acknowledged the findings.",2020-09-01
58,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,557,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview for one (1) of 56 sampled residents, the facility staff failed to treat resident with respect and dignity by entering the resident's room without knocking and announcing self before entering the resident's room. Resident# 124. Findings included . An observation on 7/10/18, at 12:30 PM of Resident# 124 room door showed a sign posted which reads knock please. Resident# 124 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 7/10/18, at 12:30 PM with Resident #124 Employee#15 was observed to walk into the Residents' room walk toward the sink and then exit the room without knocking or announcing request to enter. Employee#15 failed to knock on the Residents' door before entering the room, and after entering the room, she did not address the Resident or the Residents' roommate. After Employee#15 exited, Resident# 124 stated I did not hear a knock at all no she (Employee# 15) did not say anything after she came into the room. During an interview on 7/10/18, at 12:35 PM with Employee#15, the television was on so I came in I did not say anything because I saw you talking to the Resident. During a face-to-face meeting, Employee# 15 acknowledged the finding,",2020-09-01
59,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,558,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and interviews, the facility staff failed to provide resident with a bed mattress to meet the residents preferred comfort level to facilitate a restful night sleep. Resident# 478. Findings included Resident# 478 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During a resident interview on 7/12/18, at 10:30 AM the resident stated staff provides pain medication for pain experienced because the bed is too hard and it feels like someone is poking her and nothing has been done about the issue. An observation of the mattress on 7/12/18, at 10:30 AM showed the mattress to be inflated and the blower based pump (located at the foot of the bed) was operational. Review of the Comprehensive Minimum (MDS) data set [DATE], showed Section C (Cognitive Patterns) C0500-Brief Interview Mental Score (BIMS) of 15 (indicating the resident is cognitively intact). Section G (Functional Status) G0400-Functional Limitation in Range of Motion Resident was coded as 1 which indicates impairment on one side (upper extremity) and coded as 2 which indicates impairment on both sides (lower extremity). A review of the medical record on 7/12/18, at 11:30 AM showed a Social Work Progress Note dated 5/3/18, read Resident expressed concern with the shower chair is too hard to set on, shower bed unable to fit on due to her size (sic). During an interview on 7/12/18, at 1:00 PM with Employee# 4, confirmed that the resident had concerns about the bed mattress. Employee#4 further stated that the facility stopped using the Hoyer lift and follow-up on the mattress was pending. However, the Employee was not aware of the resident's concern about the shower chair or shower bed. The medical record lacked documented evidence that the facility addressed Resident #478's concern of a hard mattress which caused back pain. During a face-to-face interview on 7/12/18 at 2:00 P, Employees #2 and #4 acknowledged the finding.",2020-09-01
60,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,568,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review facility for 1 (one) of 56 sampled residents facility staff failed to provide resident quarterly statements to a resident representative within 30 days after the end of the quarter. Resident 477. Findings included . Record review of the facility's undated policy titled Patient Funds showed Quarterly Statements must be provided to the resident or the resident's representative within 30 days after the end of the calendar quarter. Resident# 477 admitted on [DATE], with [DIAGNOSES REDACTED]. During a family interview on 7/10/18 at 12:30 PM, the Resident's Representative was asked: Do you get a quarterly statement from the facility? The family representative responded no, should I be getting a quarterly statements. During an interview on 7/20/18 at 2:00 PM with Employee# 17, what we typically do is keep a copy or we mail a copy to the representative, here are the statements but I can't show you anything that it was mailed we don't keep record of that, but we can start. A further review of the medical record showed a Social Work Care Plan Meeting Progress note dated 4/19/18, RP (responsible party) provides visits and calls to check on Resident's medical status, family is very supportive. A review of three of Resident Fund Management Service Statements showed quarterly statements for the period of: 7/1/17-9/29/17 9/30/17-12/29/17 12/30/17-3/30/18 Facility staff failed to show evidence quarterly statements were provided to Resident #477 Responsible Party. During a face-to-face meeting on 7/20/18 at 2:00 PM Employee#17 acknowledged the finding.",2020-09-01
61,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,584,E,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to provide housekeeping services necessary to maintain a safe, clean, comfortable environment as evidenced by privacy curtains that were not secured in six (6) of 34 resident rooms, soiled exhaust vents in three (3) of 34 resident rooms and a call bell with no pull cord in one (1) of 34 resident bathrooms. Findings included . During an environmental tour of the facility on (MONTH) 11, (YEAR), between 11:15 AM and 3:00 PM, the following were observed: 1. Six (6) of 34 privacy curtains in resident's rooms (Rooms #113A, 144A, 309, 313B, 329A, 338A) hanging loose and detached from the curtain tracks which could impede the resident from closing the privacy curtains for full privacy. 2. Three (3) of 34 exhaust vents in resident's rooms (Rooms #313, 338, 344) soiled with dust particles. 3. One (1) of 34 call bell cord in the resident room bathroom in room [ROOM NUMBER] was missing. During a face-to-face interview on (MONTH) 11, (YEAR), Employee #12 acknowledged the findings.",2020-09-01
62,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,641,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 56 sampled residents, facility staff failed to code the Minimum Data Set (MDS) to reflect one (1) resident [DIAGNOSES REDACTED]. Resident #111 and 143. Findings included . 1. Resident #111 was admitted on (MONTH) 9, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident #111's annual Minimum Data Set, dated dated dated (MONTH) 31, (YEAR), showed Section I Active Diagnosis, under Psychiatric /Mood Disorder with a box next to I5700 Anxiety Disorder which was blank left which indicated the condition does not exist. A review of the Psychiatric assessment dated (MONTH) 19, (YEAR), showed [DIAGNOSES REDACTED]. During a face to face interview on (MONTH) 20, (YEAR), at approximately 4:00 PM with Employee #20, the Psychiatric Assessment was reviewed. Employee acknowledged the finding. 2. Resident #143 was admitted on (MONTH) 16, 2014, with [DIAGNOSES REDACTED]. A review of Resident #143's quarterly Minimum Data Set, dated dated dated (MONTH) 22, (YEAR), showed Section I Active Diagnosis, Psychiatric /Mood Disorder with a box next to I5800 Depression was blank left which indicated the condition does not exist. A review of the Physician interim order sheet showed an order dated (MONTH) 28, (YEAR), 4:40 PM that directed, Psych consult for Dementia in other diseases without behavioral disturbance. A review of the Psychologist assessment dated (MONTH) 4, (YEAR), showed [DIAGNOSES REDACTED]. During a face to face interview on (MONTH) 20, (YEAR), at approximately 4:00 PM with Employee #20, the Psychologist Assessment was reviewed. Employee acknowledged the finding.",2020-09-01
63,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,655,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 56 sampled residents, facility staff failed to develop baseline care plans with goals and approaches to properly care for one (1) resident with arteriovenous (AV) graft and indwelling catheter and one (1) resident with nephrostomy tubes. Residents' # 227 and #228. Findings included . 1.Facility failed develop a baseline care plan with goals and approaches to care for the residents' arteriovenous (AV) graft and indwelling catheter. Resident # 227. Resident #227 was admitted to the facility on (MONTH) 4, (YEAR), with diagnoses, which include [MEDICAL CONDITIONS] Hypertension, and Diabetes Mellitus. The resident also had an arteriovenous (AV) graft place on the left forearm for [MEDICAL TREATMENT] access and an indwelling catheter. According to health note dated (MONTH) 5, (YEAR), at 10:58 AM, read, S/P (status [REDACTED]. S/P indwelling Foley (catheter) with amber colored urine. Review of the Admission/Interim Care Plan (Baseline care plan) lacked evidence of goals and approaches to address the care needs for the left arm with the arteriovenous graft placement (such as, palpate the sight for thrill and using a stethoscope to listen for bruit and no obtaining blood pressure measurements on the residents left arm). Also, to ensure the indwelling catheter has no kinks or twists, empty the drainage bag(s) before they are full, and use of leg straps to securely hold the catheter in place). During a face-to-face interview with Employee #5 on (MONTH) 17, (YEAR), at 10:20 AM, the employee reviewed the baseline care plan and acknowledged that it did not include information regarding care of the residents arteriovenous (AV) graft and indwelling catheter. 2. Facility staff failed develop a baseline care plan with goals and approaches to care for Resident #28's nephrostomy tubes. Resident #228 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. The resident also had and indwelling catheter (nephrostomy tubes) in place. The admission note dated 7/25/18, at 23:44 (11:44 PM) reads, .Bilateral nephrostomy tubing noted patient draining straw color urine with no odor. 110cc on the left drainage bag and 50cc on the right drainage bag. Review of the Admission/Interim Care Plan (Baseline care plan) lacked evidence of goals and approaches to address the care needs to maintain the bilateral nephrostomy tubes (such as, checking the skin at the insertion sites, ensure the tubes have no kinks or twists, empty the drainage bag(s) before they are full, and flushing protocols if ordered). During a face-to-face interview with Employee #5 on (MONTH) 17, (YEAR), at 5:13 PM, she acknowledged the baseline care plan did not address care of the residents nephrostomy tubes.",2020-09-01
64,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,656,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews for three (3) of 56 sampled Residents, facility staff failed to develop a care plan that included goals and approaches for assessment of one (1) Resident AV(arteriovascular) graft/fistula access site, one (1) Resident for [DIAGNOSES REDACTED]. Resident #6, #38, and #138 Findings included . 1. Facility staff failed to develop a care plan that included goals and approaches for one (1) Resident AV graft/fistula access site. Resident #6 Resident #6 admission was on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. Diabetes Mellitus 2, Hypertension, Heart Failure, [MEDICAL CONDITION], and Cataract. A review of the quarterly MDS with ARD date (MONTH) 6, (YEAR), section I Active [DIAGNOSES REDACTED]. On (MONTH) 18, (YEAR), 11:50 AM a review of the following Nurses Progress Note showed that the Resident#6 AV graft/fistula access site for [MEDICAL TREATMENT] treatment located in her left arm clogged twice. April 11, (YEAR), 23:39 PM (Resident name) returned to the facility this afternoon at about 4 PM without being dialyzed (dialyzed), AV (Arteriovascular) graft was blocked. May 4, (YEAR), 18:08 PM Resident came back and was not dialyzed secondary to clogged AV graft. Resident scheduled for declogging on (MONTH) 5, (YEAR), at 9 am. A review of care plan showed no evidence that staff developed a care plan with goals and approaches that included the Resident's access site blockages, and pre and post [MEDICAL TREATMENT] assessment for her AV graft/fistula. The Resident's care plan lacked evidence that staff developed a care plan that included the access site blockages and assessment of the AV graft/Fistula pre and post [MEDICAL TREATMENT] treatment. A face-to-face interview conducted with Employee#19 on (MONTH) 19, (YEAR), she reviewed the care plan and acknowledged the findings 2. Facility staff failed to develop a care plan with goals and approaches for one (1) Resident for [MEDICAL CONDITION]. Resident #38 Resident# 38 admitted on (MONTH) 24, 2005, with [DIAGNOSES REDACTED]. A review of the Annual MDS with ARD date (MONTH) 2, (YEAR), section I Active [DIAGNOSES REDACTED]. A review of physicians order dated (MONTH) 29, (YEAR), 10:00 AM showed Psych to evaluate and treat as needed for [MEDICAL CONDITION], Impulsive disorder. A review of care plan showed no evidence that staff developed a care plan with goals and approaches to address the Resident's [MEDICAL CONDITION]. The Resident's care plan lacked evidence that staff develops a care plan with goals and approaches to address [DIAGNOSES REDACTED]. A face-to-face interview conducted with Employee#19 on (MONTH) 19, (YEAR), she reviewed the care plan and acknowledged the findings. 3[NAME] Facility staff failed to develop a care plan with goals and approaches for one (1) Resident [DIAGNOSES REDACTED].#138 Resident# 138 admitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the Quarterly MDS with ARD date (MONTH) 19, (YEAR), section I Active [DIAGNOSES REDACTED]. A review of the Physician orders [REDACTED]. A review of care plan showed no evidence that staff developed a care plan with goals and approaches that included the Resident's [DIAGNOSES REDACTED]. The Resident's care plan lacked evidence that staff develops a care plan with goals and approaches to address [DIAGNOSES REDACTED]. A face-to-face interview conducted with Employee#19 on (MONTH) 19, (YEAR), she reviewed the care plan and acknowledged the findings 3B. Facility staff failed to develop a care plan with goals and approaches for one (1) Resident for a resident Rehab Services. Resident#138 Resident# 138 admitted on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the Quarterly MDS dated (MONTH) 19, (YEAR), showed Section O0400 Therapies B. Occupational therapy started (MONTH) 20, (YEAR), and therapy ended (MONTH) 7, (YEAR). A review of care plan showed no evidence that staff developed a care plan with goals and approaches to address Resident Rehab Services. The Resident's care plan lacked evidence that staff develops a care plan with goals and approaches to address [DIAGNOSES REDACTED]. A face-to-face interview conducted with Employee#19 on (MONTH) 19, (YEAR), she reviewed the care plan and acknowledged the findings.",2020-09-01
65,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,657,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interview for three (3) of 56 sampled Residents, the facility failed to update the care plan to include goals and approaches to address one (1) resident with a low [MEDICATION NAME] level, one (1) resident nutritional diet change, and one (1) resident that sustained a fall. Resident #6, #158 and #327. Findings included . 1. Facility staff failed to update the care plan to include goals and approaches to address Resident #6 low [MEDICATION NAME] level. Resident #6 admission was on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the quarterly Minimum Data Set (MONTH) 6, (YEAR), section I Active [DIAGNOSES REDACTED]. Observation on (MONTH) 11, (YEAR), 10:30 AM showed Resident #6 on the way to [MEDICAL TREATMENT], accompanied by a staff member with the communication medical record binder. Review of the Nutrition Progress Note on (MONTH) 20, (YEAR), at 3:00 PM showed the RD (Registered Dietitian) received a consult notice from RNP (Registered Nurse Practitioner) and [MEDICAL TREATMENT] regarding marginally low [MEDICATION NAME] reading. Resident's [MEDICATION NAME] was 3.4 gram per deciliter on a 3.5-5.5 gram scale. [MEDICAL TREATMENT] goal is 4 gram. The resident will receive 30 milliliters of Pro Source by mouth every day until the next [MEDICATION NAME] reading. A review of the resident's Nutrition/[MEDICAL TREATMENT] care plan lacked evidence that the facility updated the care plan with goals and approaches to reflect a low [MEDICATION NAME] level. During a face-to-face interview on (MONTH) 19, (YEAR) at 3:15 PM, Employee#19 reviewed the care plan and acknowledged the findings. 2. Facility staff failed to update the care plan to include goals and approaches for Resident #158 nutritional diet change. Resident #158 admission was on (MONTH) 12, (YEAR), with [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set, dated dated dated (MONTH) 19, (YEAR), Section K0310 Nutritional Approaches under C showed Mechanically altered diet - require a change in the texture of food or liquids. A review of physician order [REDACTED]. A review of the Resident's care plan showed a care plan for Nutrition Problem: Mastication difficulty related to medical state as evidenced by mechanical soft diet order date initiated (MONTH) 15, (YEAR). The Resident's care plan lacked evidence that the facility updated the care plan with goals and approaches to reflect Regular diet, Regular texture, Nectar consistency, Nectar thick liquids Double Portion entree per meal every shift when the diet order changed on (MONTH) 20, (YEAR). During a face-to-face interview on (MONTH) 19, (YEAR), at 3:15 PM, Employee#19 reviewed the care plans and acknowledged the findings. 3. Facility staff failed to update the care plan to include goals and approaches to address Resident #327 fall. Resident #327 initially admitted on (MONTH) 4, (YEAR), and hospitalized briefly. On (MONTH) 7, (YEAR), Resident #327 was readmitted with [DIAGNOSES REDACTED]. During a resident representative interview on (MONTH) 11, (YEAR), at 3:33 PM, the resident responsible party stated the staff told her that the resident had fallen and has a bruise on the back and left arm. Review of the admission Minimum Data Set, dated dated dated (MONTH) 11, (YEAR) showed Resident #327 was severely cognitively impaired as coded in Section B Cognitive Status C0500. Brief Interview for Mental Status (BIMS) Summary Score of three (3). In addition, the resident's self-performance required extensive assistance (resident involved in activity, staff provide weight-bearing support) with bed mobility, transfer, dressing, toilet use and personal hygiene as coded in Section G Functional Status Activities of Daily Living Assistance (ADLs) as three (3); and support from staff for activities of daily living provided by staff was coded as one (1) one person physical assist. A review of Nursing Notes showed Resident #327 fell on (MONTH) 9, (YEAR), at 9:15 AM, in dayroom and was later observed on the floor of his room at 11:00 AM. A review of the resident's care plan showed a care plan for Potential risk for falls related to limited mobility initiated (MONTH) 7, (YEAR). However, Resident #327's care plan lacked evidence that the facility updated the goals and approaches to address the falls Resident #327 sustained on (MONTH) 9, (YEAR). During a face-to-face interview on (MONTH) 19, (YEAR), at 3:15 PM, Employee#19 and Employee #3 acknowledged the findings.",2020-09-01
66,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,660,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview and staff interview for one (1) of 56 sampled residents the facility staff failed to provide a listing of providers and data to facilitate a transfer to another skilled nursing facility for one resident. Resident# 477. Findings included . Resident# 477 admitted on [DATE], with [DIAGNOSES REDACTED]. During a family interview on 7/11/18, at 11:45 AM the resident representative stated the facility was informed of the family's desire to have the resident transferred to a nursing home in Virginia, to be closer to spouse. According to the resident representative, the social worker contacted the facility;however, no further information has been provided to the family. A review of the medical record on 7/12/18, at 2:00 PM showed a Social Worker Progress Noted dated 4/19/18, Resident Care Plan Meeting was held today, team members were in attendance. Resident husband resides at a nursing facility in Virginia; Residents son expressed an interest in reuniting them in the same facility, SW (Social Worker) will continue to provide weekly visits to monitor Resident's overall welfare . A review of the Comprehensive Minimum Data Set ((MDS) dated [DATE], showed Section Q0400. Discharge Plan- [NAME] Is active discharge planning already occurring for the resident to return to the community the code entered is 0 which indicates no. During an interview on 7/12/18, at 11:00 AM, Employee# 4, stated the family informed the facility that they desired to transfer the resident to a nursing home in Virginia to be closer to her husband. Also, the social worker previously assigned to the unit is no longer employed at the facility. A further review of the medical record on 7/12/18, showed resident receives Occupational Therapy for therapeutic activities. The Occupational Therapy note dated 7/19/18, showed nursing and occupational therapy conferring to coordinate best times for medication administration to optimize occupational therapy and treatments. During an interview on 7/19/18, at 2:00 PM with Employee# 4, acknowledged Resident# 477's representative's desire to transfer the resident to another skilled facility in Virginia. During a face-to-face interview on 7/19/18, at 2:30 PM Employee # 4 acknowledged the finding.",2020-09-01
67,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,677,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 56 sampled residents, the facility staff failed to provide adequate grooming services by failing to provide nail care for one (1) resident who was totally dependent on staff for all of his care. Resident #112. Findings included . Resident #112 was admitted to the facility on (MONTH) 18, (YEAR) with [DIAGNOSES REDACTED]. Observation on (MONTH) 12, (YEAR) showed Resident #112 lying in bed. The resident's nail edges were broken and jagged with black material underneath the nailbeds. Review of Resident #112's medical record showed an admission Minimum Data Set (MDS) with an assessment reference date (ARD) of (MONTH) 27, (YEAR). Section G (Functional Status) G0110 activities of daily living (ADL) assistance, the resident was coded as a three (3) for bed mobility, transfer, toilet use, dressing and locomotion, indicating the need for extensive assistance in all of the aforementioned areas. The support level coding for the ADLs was coded as a two (2), indicating the need for one (1) person's physical assistance to perform the activities, except in transfer, where it was coded as a three (3), indicating the need for physical assistance from two or more persons for transfer. During a face-to-face interview on (MONTH) 16, (YEAR) at approximately 2:30 PM, Employee #5 reviewed Resident #112's nails and stated the resident is very noncompliant with grooming and refuses care. A review of Interdisciplinary Team Meeting notes of (MONTH) 27, (YEAR) showed that the Resident #112's Responsible Party (RP) was informed of the elongated nails which were digging into his skin. RP was informed of the plan to initiate psychiatric consult. The medical record lacked documented evidence of follow-up interventions provided related to refusal to have nails trimmed and cleaned for a resident totally dependent for all care needs. Employee #5 acknowledged the finding on (MONTH) 16, (YEAR).",2020-09-01
68,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,684,G,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, personnel records review and staff interviews for two (2) of 56 sampled residents, the facility failed to provide necessary care and treatment with an acute change in condition as evidenced by failure to perform a comprehensive assessment and reassessments to determine appropriate treatment and interventions to prevent Harm and prevent hospitalization for one (1) resident (Resident #158) with [DIAGNOSES REDACTED].#158, and #96. Findings included . 1. Facility failed to provide necessary care and treatment with an acute change in condition as evidenced by failure to perform a comprehensive assessment and reassessments to determine appropriate treatment and interventions to prevent hospitalization for Resident #158. On (MONTH) 17, (YEAR), the State Agency received a facility reported incident that showed that Resident # 158 experienced a choking episode with total airway obstruction on (MONTH) 17, (YEAR) at approximately 9:50 PM. The resident subsequently became unresponsive. Cardiopulmonary resuscitation was initiated and the resident was transported to the emergency room . Resident #158 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Speech Evaluation and Plan of Treatment dated (MONTH) 13, (YEAR) at 4:38 PM showed reason for referral: Resident referred to SLP (Speech Language Pathology) evaluation due to difficulty speaking and coughing while eating. The speech evaluation included recommendations for mechanical soft textures, mechanical soft/ground textured solids; nectar thick liquids with close supervision for oral intake. Swallowing strategies included seated in chair or edge of bed for all PO (oral) intake. Liquids consumed with head posture chin down. Review of medical record on [DATE] at 10:00 AM showed an Admission Minimum Data Set ((MDS) dated [DATE]. Review of the MDS Section C showed the Brief Interview for Mental Status score was coded as 13, which indicates the resident is cognitively intact. Section G0110 (Functional Status) Resident # 158 was coded as requiring supervision for all activities of daily living except bed mobility, personal hygiene and bathing. Under section G0120 (Bathing) resident is coded as 4 which indicates total dependence. Section G0110 Eating resident was coded as 1 which indicates set up help only. Under Section K0100 (Swallowing/Nutritional Status) resident was coded as none of the above for Swallowing Disorder. However, under Section K0510 (Nutritional Approaches) the resident is coded as requiring a mechanically altered diet (requires change in texture of food or liquids, e.g. pureed food, thickened liquids). Review of the Nutrition problem care plan dated [DATE], showed interventions listed as provide regular mechanical soft diet as ordered. A further review showed an ADL Self-care Performance Deficit care plan initiated on [DATE], with the following interventions praise all efforts at self-care, physical therapy and occupational therapy evaluation and treatment as per doctor orders, staff to assist with bed mobility and transfers, as well as locomotion on and off unit as needed, staff to assist with hygiene and toileting as needed, encourage resident to participate to the fullest extent possible with each interaction and encourage resident to use call bell to call for assistance. Review of the Oral/Dental Health problem care plan dated [DATE] showed the resident has difficulty in chewing and broken teeth need for altered textured diet, Interventions the resident requires mechanical soft diet. Consult with dietician and change if chewing/swallowing problems are noted. The medical record lacked documented evidence the care plan included swallow strategies recommended by the speech therapist. Speech Therapy Treatment Encounter note dated [DATE] at 5:42 PM, showed regular nectar thin liquids presented mild cues for head posture chin down during liquid intake. The Nurse's Note dated (MONTH) 17, (YEAR), at 11:15 PM showed that Resident #158 was in the Day Room with other residents eating a steak and cheese sub from a local carry out when a staff member yelled for help at about 9:40 PM. Upon entering the Day Room, the nurse observed the resident sitting in his wheelchair coughing/choking and his eyes rolling backward. The nurse called for help and performed five (5) back blows on each shoulder blades. Resident #158 coughing increased. In addition, the Nurse's Note showed abdominal thrusts were performed three (3) times but the resident condition is not improved. He went into code and CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called, resident was intubated and then transferred to (Hospital Name). The medical record lacked documented evidence the nursing staff provided verbal cues to Resident #158 while eating the steak and cheese in the Day Room, to prevent choking. Further review of the medical record showed an eInteract Change of Condition Evaluation Form dated (MONTH) 17, (YEAR), at 9:59 PM. The form showed Resident #158's [DIAGNOSES REDACTED]. The most recent vital signs recorded as [DATE] at 9:40 AM- ,[DATE], pulse- 78 beats per minutes, respirations- 20 breaths per minutes, and the most recent temperature recorded as 98.4 degree Fahrenheit orally at 2:28 PM on (MONTH) 17, (YEAR). The most recent oxygen saturation recorded as 98% (percent) on (MONTH) 16, (YEAR) at 11:03 PM. The physical assessment showed Resident #158 had no observed neurological changes but was also unresponsive, and choking. Under section summarize your observations and evaluation: Resident was eating outside food steak and cheese sandwich when he began choking. The interventions documented were 911 was called and CPR continued, resident was transported via 911. However, the eInteract Change of Condition Evaluation Form failed to show all interventions implemented to include complete vital signs, administration of oxygen, suctioning and the performance of a comprehensive assessment cardiovascular assessment, respiratory assessment, and neurological assessment at and during the change of condition. Review of the report submitted to the State Agency showed that on (MONTH) 17, (YEAR), at 9:50 PM, in the 3rd Floor Day Room, Resident #158 choked with total airway obstruction while eating a steak and cheese, and became unconscious for about one minute until airway was partial opened. According to the facility report, the [MEDICATION NAME] maneuver was performed and partial opened the airway. The staff administered oxygen via a mask and Ambu bag. Audible wheezing and sweating was observed and resident was lowered to the floor. Cardiopulmonary Resuscitation was initiated simultaneously with intermittent application of oxygen with Ambu bag. The Emergency Medical Services team arrived about three minutes after the [MEDICATION NAME] Maneuver, at which time they administered [MEDICATION NAME] and the Automated External Defibrillator was placed. Review of the facility policy titled Serenity Rapid Response Team dated (MONTH) 27, (YEAR), showed that staff are to respond to all emergencies to include a licensed nurse from each unit and the Director of Nursing/Nursing Supervisor, and Nurse Practitioner , if available. The Director of Nursing/Nursing Supervisor is responsible for bringing the AED (Automated External Defibrillator); while the other assignments are as follows: [NAME] Nurse assigned to the resident stays with the resident and directs the other staff to contact the Rapid Response Team and 911. B. Unit One Team 3 Nurse brings the Crash Cart to the scene of the emergency regardless of the location. C. Unit Two Team 3 Nurse is responsible for providing oxygen, suctioning, and ventilation with the bag valve, if necessary. D. Unit Three- Team 3 Nurse assists with placing the cardiac board under the resident and providing the compressions. During a face-to-face interview on [DATE] with Employee#26 at 4:21 PM regarding the resident's change in condition, I completed the Nursing Home to Hospital Transfer Form on [DATE] and I assisted with CPR (cardiopulmonary resuscitation) for Resident# 158. When I came in the dayroom I saw the resident trying to stick his hand down his throat , we (staff) were trying to get him to stand and he could not stand he was conscious and I was telling him to cough and Employee# 25 did the back slaps over his shoulder blades, he had cup of water he was trying to drink it and it was coming out of his mouth, then he could not breathe he was shaking and he became stiff and he was not breathing and we started CPR we called a code and 911, the supervisor (Employee# 27) came to the floor and took over CPR. During a face-to-face interview with Employee #27 on [DATE] at 5:00 PM, they called a medical emergency and I came from the first floor and I met the Resident# 158 holding his throat he said that he just choked he stood up and we supported him I did the [MEDICATION NAME] Maneuver and then we placed him on the floor and I took over CPR, oxygen and suction with a Yankeur (oral suction tool), by now 911 had arrived and his SP02 (oxygen level) was 62% they (911) took over chest compressions with an automatic chest compression system they (staff) pulled out a big piece of meat, he was alive when he left the floor he was to go (hospital name) but he went to (hospital name). During a telephone interview on [DATE], at 5:35 PM, Employee# 24, stated I was in the dayroom but I was not assigned to the resident and three residents came in with food from the outside; Resident#158 and two other residents. I was not too far away and he asked for sips of water, thickened water. While they were eating I gave him the thickened water and then I asked him if he was choking. He said yes, he only took a few bites before he started choking. It was not a long time at all, if ten minutes, before he started choking. He had a lot of sandwich left. I saw staff in the hall way and called for help they came in and started working on him. Employee #25 provided back slaps over the shoulders blades for Resident # 158's choking episode. However, backs slap are inconsistent with the [MEDICATION NAME] maneuver to address choking in adults and can further lodge food in airway. The [MEDICATION NAME] maneuver includes the performance of abdominal thrust and chest thrust to dislodge foreign object from airway. Pavitt, M. [NAME], Swanton, [MI] [MI], Hind, M., Apps, M., Polkey, M. I., Green, M., & Hopkinson, N. S. (2017). Choking on a foreign body: A physiological study of the effectiveness of abdominal thrust maneuvers to increase [MEDICATION NAME] pressure. Thorax, 72(6), 576. doi:http://dx.doi.org.contentproxy.phoenix.edu/10.1136/thoraxjnl-,[DATE] Review of personnel record showed, Employee #25 received Cardiopulmonary Resuscitation training to include the [MEDICATION NAME] maneuver. The medical record lacked documented evidence of monitoring and assessment to include the recording of physiological signs and symptoms of distress when the resident's condition declined prior to transfer to the Emergency Department. The facility's failure to assess, implement interventions, and properly intervene placed Resident #158 at harm. The facility's failure to assess, implement interventions, and properly intervene lead to Resident #158's harm and subsequent death. 2. Facility staff failed to provide treatment and care in accordance with professional standards of practice for Resident #96. Resident #96 was admitted to the facility on [DATE] (initial admitted ) with [DIAGNOSES REDACTED]. Resident interview on [DATE],8 at 3:30 PM the Resident was asked, do you have any problems with vision or hearing? Resident stated I have not had an eye appointment and they stopped giving me my eye drops for my [MEDICAL CONDITION] my vision is real blurry now. Review of the medical record on [DATE], at 9:30 AM showed a physician order dated [DATE] Ophthalmology Consultation for Resident with [MEDICAL CONDITION], [MEDICATION NAME]/[MEDICATION NAME], 0.004% eye drop 1 gtt (drop) to both eyes Q HS (every bedtime) DX (diagnosis) [MEDICAL CONDITION], Dorzolamide-[MEDICATION NAME] 2%-0.5% eye drop 1 gtt (drop) to both eyes BID (twice a day) Dx [MEDICAL CONDITION]. A further review of the medical record showed a Compressive Minimum Data Set (MDS) dated (MONTH) 15, (YEAR), Section B Hearing, Speech and Vision (B1000). Vision ability to see in adequate light (with glasses or other visual appliances), the code entered is 1 which indicates Impaired-sees large print, but not regular print in newspaper/books. (B1200) Corrective lenses (contacts, glasses or magnifying glass) used in completing (B1000), Vision the code entered is 0, which indicates no. A review of the medical record on [DATE] at 10:30 AM showed Medication Administration Record [REDACTED] The medication administration showed eye drops were administered to Resident #96 during the months of September, (YEAR) October, (YEAR) November, (YEAR) December, (YEAR) A further review of the medical record on [DATE] at 11:30 AM showed Resident # 96 Medication Administration Record [REDACTED] January (YEAR) February (YEAR) March (YEAR) April (YEAR) May (YEAR) June (YEAR) July (YEAR) However, the Medication Administration Records did not show the order for eye drops Dorzolamide HC-[MEDICATION NAME] Mal Solution 22XXX,[DATE].8 MG/ML (milligram/milliliter) one drop in both eyes two times a day for [MEDICAL CONDITION] and Dorzolamide-[MEDICATION NAME], 2%-0.5% Drops, instill 1 drop in both eyes two times a day for [MEDICAL CONDITION] was transcribed or that the Resident received the eye drops for the past seven months. During an interview on [DATE], at 12:30 PM, Employee# 4, stated I see the eye drops are not on the MAR (medication administration record) and I don't see an order to stop them, let me keep looking. During a telephone interview on [DATE], at 1:00 PM the Physician, stated the Resident had multiple hospitalization s and that is why he (Resident) may not have had the Ophthalmology Consult, and the order for eye drops check to see if the eye drops are on the discharge hospital paperwork, but I understand that he should have received the eye drop order for eye drops. During an interview with Employee #4 on [DATE], at 3:00 PM Employee stated no I could not find that the resident received the eye drops since (MONTH) of (YEAR), the Resident did go in and out of the hospital, he did not receive the eye drops at all this year. Facility staff failed to provide evidence Resident # 96 was provided care and treatment (administration of eye drops) in accordance with professional standards of care. During a face-to-face interview on [DATE], at 3:00 PM Employee# 4 acknowledged the findings at the time of the observation. A further review of the medical record on [DATE], at 10:00 AM showed a physician's order dated [DATE] Latanoprost 0.005% ophthalmic solution (eye drop) at bedtime every day and Dorzolamide HCL Solution 2% one drop twice a day every day. During a face-to-face interview on [DATE], at 10:00 AM Employee# 4 stated here is the order and again acknowledged the finding.",2020-09-01
69,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,685,E,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for four (4) of 56 sampled residents, facility staff failed to assist Resident #3 to obtain services that would include complete hearing evaluation to determine the extent of her hearing loss; and obtain a hearing device to correct and/or improve the resident's ability to hear if necessary; and for two residents (2) needing assistance with scheduling appointments for vision services Resident # 68 and Resident# 96 and to assist Resident #127 in obtaining glasses (which she needs for reading) to replace her broken glasses and failed to ensure residents received proper treatment to maintain vision abilities by failing to schedule ophthalmology appointments for two (2) residents. Residents' #3, #68, #96 and #127. Findings included . 1. Resident #3 was admitted to the facility on (MONTH) 14, (YEAR) with [DIAGNOSES REDACTED]. On (MONTH) 11, (YEAR) at approximately 11:00 AM I attempted to interview Resident #3 without success. Employee #9 had advised me prior to the interview that I needed to face the resident and yell loudly; as she (the resident) had difficulty hearing. However, the resident looked at me when I spoke, slapped her right ear intermittently and uttered no verbal response to the questions I asked. A review of the resident's annual minimum data set (MDS) with an Assessment Reference Date (ARD) of (MONTH) 1, (YEAR) Section B0200 (Hearing) shows the resident coded as a two (2) indicating that the resident has moderate difficulty hearing (speaker has to increase volume and speak distinctly). In B0300 (Hearing Aid) the resident wears no hearing aid or hearing appliance. Under B0600 (Speech Clarity) speech is unclear with slurred or mumbled words. Under B0700 (Makes Self Understood) she has difficulty communicating some words or finishing thoughts and under B0800 (Ability to understand) she misses some part/intent of message. A review of the resident's clinical record showed a neurologist's report which provided the following information. Hearing is markedly lost with tuning fork examination. Under Assessment the neurologist documented that the resident was markedly hard of hearing and under Plan he stated that the resident needs to see an audiologist for possible Hearing Aids. However, Resident #3's clinical record lacked evidence that she received an audiological evaluation. A face-to-face interview was conducted with Employee #5 at approximately 11:00 AM on (MONTH) 13, (YEAR). In response to the question of whether the resident received an audiological evaluation the employee stated that she thought that the resident had received the evaluation. However, she was unable to provide a report of the evaluation. At approximately 2:00 PM on (MONTH) 16, (YEAR) Employee #5 presented a faxed copy of a report of a Diagnostic Audiology Visit. The date of the visit was (MONTH) 05, (YEAR). The date printed on the bottom of the report was 07/16/2018 13:10 EDT indicating that the report was printed on (MONTH) 16, (YEAR) at 13:10 Eastern Daylight Time. The recommendation of the audiology evaluation is listed below: It is recommended that the patient return for Auditory Brainstem Response (ABR) testing under the influence of sedation, if medically/legally permissible, to further determine hearing status as today's findings are suggestive of some degree of hearing loss and patient was unable to perform behavioral tasks. Patient should be sedated to the point of sleep for 1-2 hours of testing if medically and legally permissible. After I reviewed the report I asked the employee whether the ABR testing was was ever conducted. She stated that the test was never done and added that she will make arrangements to have the test completed as soon as possible. Facility staff failed to assist Resident #3 to obtain services that would include complete evaluation and obtaining hearing device to correct and/or improve the resident's ability to hear. Employee #5 acknowledged the finding. 2 Facility staff failed to assist resident with scheduling an eye exam. Resident #68 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the medical record on 7/10/18, showed a Compressive Minimum Data Set (MDS) dated (MONTH) 18, (YEAR), Section B Hearing, Speech and Vision (B1000). Vision ability to see in adequate light (with glasses or other visual appliances), the code entered is 1 which indicates Impaired-sees large print, but not regular print in newspaper/books. (B1200) Corrective lenses (contacts, glasses or magnifying glass) used in completing (B1000), Vision the code entered is 0, which indicates no. During a Resident interview on 7/10/18, at 4:15 PM, Resident# 68 stated she has problems with vision and the facility is aware. During an interview with Employee# 4 on 7/11/18 at 3:30 PM Employee #4 the employee reviewed the medical record and stated the record lack evidence of a completed or scheduled eye appointment. Employee#4 requested additional time to look into the matter. In follow-up on 7/17/18 at 1:00 PM Employee# 4 stted as a result of being unable to locate a record of an eye appointment the facility completed a Request for Medical Care Senior Vision Services dated 7/17/18, for Resident #68. The medical record lacked documented evidence the facility assisted the resident in making an appointment to obtain vision services. Facility staff failed to ensure the resident with impaired vision received proper treatment to maintain vision ability by failing to schedule an eye appointment. During a face-to-face interview on at 7/17/18 at 3:00 PM, Employee# 4 acknowledged the finding. 3. The facility staff failed to schedule an opthamology consult for a resident with [MEDICAL CONDITION] in accordance with the physicians order. Resident# 96 was admitted to the facility on [DATE] (initial admitted ) with [DIAGNOSES REDACTED]. A review of the medical record showed Review of the medical record on showed a Compressive Minimum Data Set ((MDS) dated [DATE], Section B Hearing, Speech and Vision (B1000). Vision ability to see in adequate light (with glasses or other visual appliances), the code entered is 1 which indicates Impaired-sees large print, but not regular print in newspaper/books. (B1200) Corrective lenses (contacts, glasses or magnifying glass) used in completing B1000, Vision the code entered is 0, which indicates no. During a resident interview on 7/10/18 at 3:00 PM , Resident #96 stated that the facility stopped administering [MEDICAL CONDITION] eyedrops, vision is blurry and he has not had an eye exam. Physician order [REDACTED]. The medical record lacked documented evidence the Opthamology was perforemed as ordered. Further review Resident#68 showed interventions to include Resident has impaired visual function related to [MEDICAL CONDITION], Intervention: Vision Consult. During an interview with Employee# 4 on 7/11/18 at 2:00 PM Employee# 4 sates there was no evidence the resident was seen for the Opthamology consult. During an interview with Employee#4 on 7/17/18 at 4:00 PM Employee #4 stated the physician was notified about the Opthamology consult for Resident # 96 and another was obtained. During a face-to-face interview on 7/17/18 at 4:30 PM Employee# 4 acknowledged the finding. 4. Facility staff failed to assist Resident #127 in obtaining glasses (which she needs for reading) to replace her broken glasses. On (MONTH) 10, (YEAR) Resident #127 showed me what she uses to read. The resident demonstrated her broken glasses. There was no shaft on either side to enable the resident to wear the glasses. The resident held the bridge with the lens on either side to demonstrate to me how she attempts to read. She stated, I try to read like this but it is difficult. I love to read and miss not being able to do so. Resident #127 was admitted to the facility on (MONTH) 26, (YEAR) with [DIAGNOSES REDACTED]. Review of section G (Functional Status) in G0110 Activities of Daily Living (ADL) assistance, the resident is coded as a zero (0) for bed mobility, transfer, locomotion, toilet use, personal hygiene, indicating that she performs these activities independently. In section G0 300 Balance During Transitions and Walking; moving from seated to standing, walking, turning around, and moving on and off toilet she is coded as a one (1) indicating that she was not steady but able to stabilize without staff assistance when completing these tasks and used an assistive device when walking. Under section G0 400 Functional Limitations in Range of Motion she is coded as a two (2) for upper and lower extremities indicating that she has impairments on both sides. Review of the care plans and progress notes showed no documentation about the resident's broken glasses. A face-to-face interview was conducted with Employee #5 at approximately 10:00 AM on (MONTH) 18, (YEAR). During the interview the employee was asked about the lack of documentation about the resident's glasses. The employee acknowledged that she was unaware of the broken glasses and that the facility staff failed to assist Resident #127 in obtaining glasses for reading.",2020-09-01
70,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,688,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews for two of (2) of 56 sampled residents, facility staff failed to apply hand splints to prevent contractures for residents with an identified limited range of motion and to provide a shoulder sling for the residents. Residents' #68 and #478. Findings included . 1. Resident# 68 was admitted to the facility with [DIAGNOSES REDACTED]. During an observation on 7/10/18 at 10:00 AM showed Resident #68 lying on her bed holding her left arm close to her torso. A subsequent observation on 7/10/18, at 4:20 PM showed Resident #68 in resident's room listening to music with left arm close to her body. During a Resident interview on 7/11/18 at 10:00 AM the Resident stated that a sling used to support the left arm. However, staff is not applying the sling. The splint was observed in a plastic bag pinned in the wall in the resident's room. Review of the medical record on 7/11/18, at 11:30 AM showed a physician's orders [REDACTED]. A further review of the medical record on 7/11/18 at 11:30 AM showed an Occupational Therapy phone order dated 4/19/18, Left Upper Extremity hand and wrist splint provided for positioning, Treatment 3-5x\week x 83 days as tolerated. A further review of the medical record on 7/11/18 at 11:30 AM showed a Rehabilitation Daily Note dated 6/21/18 patient seen and examined by the bedside, she states that no one has stretched her LUE (left upper extremity) in three weeks or put her brace on. The medical record lacked documented evidence the left hand, and wrist splint and left arm sling were applied as ordered. During a face-to-face interview with Employee #4 on 7/11/18, at 3:30 PM, the employee stated the restorative aide was on vacation and is normally responsible for applying the resident ' s splint. During an interview with Employee #16 on 7/12/18 at 11:37 AM, the employee stated that if the resident refuses or complains of hand pain, the splint is not applied. However, when asked for documentation of the refusal, Employee #16 stated it was not available. 2. Resident # 478 was admitted to the facility with [DIAGNOSES REDACTED]. An observation on 7/10/18, at 1:00 PM showed Resident #478 sitting in Geri-chair with left-hand fingers tightly held in place. A subsequent observation on 7/12/18, at 11:30 AM showed Resident #478 sitting in Geri-chair with left-hand slight bent and fingers tightly fixed. During a Resident interview on 7/12/18, at 1:00 PM the Resident was asked what are staff doing to help with your limited motion? The resident responded, I have a splint it ' s in the back of my wheelchair look back there you will see it, (observed splint device in the back of the resident ' s wheelchair). Review of the medical record on 7/12/18, at 3:00 PM showed a physician's order [REDACTED]. During an interview with Employee #4 on 7/12/18, the Employee stated: our Restorative Aide is on vacation she would normally make sure the splints are applied daily. Employee# 4 could not provide further insight into the failure of the hand splint to be applied as per the physician's orders [REDACTED].>During a face-to-face interview with Employee #4 on 7/12/18, at 4:00 PM, present at the time of the observation and record review acknowledged the finding.",2020-09-01
71,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,689,E,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review and interview, for one (1) of 56 sampled residents the facility failed to provide an environment free from accident hazards as evidenced by several remote bed controllers cords that were frayed in six (6) of 34 resident rooms. Resident#158. Findings included . During observations throughout the facility on (MONTH) 11, (YEAR), between 11:15 AM and 3:00 PM, remote bed controller electrical cords were frayed in resident room [ROOM NUMBER] (A and B beds), 131, 222B, 229A, 313 (A and B beds), 322A, six (6) of 34 resident rooms surveyed. The uncovered, exposed electrical wires created a potential electrical shock hazard to residents, staff and the public. During a face-to-face interview on (MONTH) 11, (YEAR), Employee #12 acknowledged these findings at the time of observation.",2020-09-01
72,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,693,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 56 sampled residents, facility staff failed to record the date and time on the enteral feeding bag for Resident #37 who is fed by enteral means. Findings included . According to the manufactures, instructions: Storage -The following instructions are regarded as generally applicable to all Nestle Health Science products in this guide. To maintain product quality .hang time of spiked 1 L or 1.5 L Ultrapak(R) liquid formulas is 48 hours at room temperature. Retrieved from https://www.nestlehealthscience.ca/asset-library/documents/nhs%20product%20guide% 7%20en%20final.pdf Resident #37 was admitted to the facility on (MONTH) 30, 2013, with [DIAGNOSES REDACTED]. Also, the resident has a gastrostomy tube in place an is fed by enteral means. The physician's orders [REDACTED]. During an observation of the resident on (MONTH) 10, (YEAR), at approximately 11:49 AM, one bag of [MEDICATION NAME] 1.5 enteral feed was hanging and delivering product to the resident. The resident's name, the date, time and rate of feeding was not recorded on the label affixed to the bag. Employee #18 who was present at the time of the observation acknowledged the finding and stated, Since we don't know the date and time it (the bag of enteral feed) was hung, I will replace it. Facility staff failed to record the date and time on the enteral feeding bag so that staff may ensure the feeding hung has not exceeded the 48-hour hang time.",2020-09-01
73,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,711,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 56 sampled resident, the physician failed to review the resident's total program of care for the continuation of eye drops to treat the Resident ' s eye condition ([MEDICAL CONDITION]). Resident #96. Findings included . Resident# 96 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the medical record on 7/13/18 at 9:30 AM showed a physician order [REDACTED]. A review of the medical record on 7/13/18 at 10:30 AM showed Medication Administration Record (MAR) Schedule for (MONTH) (YEAR)-December (YEAR) reads Dorzolamide HC-[MEDICATION NAME] Mal Solution 22.3-6.8 MG/ML (milligram/milliliter) one drop in both eyes two times a day for [MEDICAL CONDITION] and Dorzolamide-[MEDICATION NAME] 2%-0.5% Drops instill 1 drop in both eyes two times a day for [MEDICAL CONDITION] The medication administration showed eye drops were administered to Resident#96 during the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR). A further review of the Medication Administration Record on 7/13/18 at 11:30 AM failed to show Resident # 96 received eye drops since (MONTH) (YEAR). During an interview on 7/16/18, at 12:30 PM, Employee# 4, stated I see the eye drops are not on the MAR and I don ' t see an order to stop them, let me keep looking. During a telephone interview on 7/16/18, at 1:00 PM with Employee#14 stated the Resident had multiple hospitalization s and that is why he (Resident) may not have had the Ophthalmology Consult, and the order for eye drops check to see if the eye drops are on the discharge hospital paperwork, but I understand that he should have received the order for eye drops, so he (Resident) could have gotten them (eye drops). Employee #14 could not provide further insight as to why the eye drops were not prescribed for the Resident ' s eye condition ([MEDICAL CONDITION]). During an interview with Employee#4 on 7/16/18, at 3:00 PM Employee stated no I could not find that the resident received the eye drops since (MONTH) of (YEAR), the Resident did go in and out of the hospital, but as far as I see the Resident did not receive the eye drops at all this year. Facility staff failed to provide evidence that Resident #96 received eye drops for the past seven months to treat eye condition ([MEDICAL CONDITION]). A further review of the medical record on 7/17/18, at 2:00 PM showed a physician's orders [REDACTED]. During a face-to-face interview and phone interview on 7/16/18, at 4:00 PM Employee#4 and #14 acknowledged the finding.",2020-09-01
74,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,726,G,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to ensure the nursing staff provided necessary care and treatment with an acute change in condition as evidenced by the failure to monitor, assess, evaluate and implement interventions, in accordance with professional standards of care, for one (1) resident with a history of dysphagia that experienced a choking episode. (Resident #158) Findings included . Resident #158 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The Speech Evaluation and Plan of Treatment dated (MONTH) 13, (YEAR) at 4:38 PM showed reason for referral: Resident referred to SLP (Speech Language Pathology) evaluation due to difficulty speaking and coughing while eating. The speech evaluation included recommendations for mechanical soft textures, mechanical soft/ground textured solids; nectar thick liquids with close supervision for oral intake. Swallowing strategies included seated in chair or edge of bed for all PO (oral) intake. Liquids consumed with head posture chin down. Review of medical record on [DATE], at 10:00 AM showed an Admission Minimum Data Set ((MDS) dated [DATE]. Review of the MDS Section C showed the Brief Interview for Mental Status score was coded as 13, which indicates the resident is cognitively intact. Section G0110 Eating resident was coded as 1 which indicates set up help only. Section K0510 (Nutritional Approaches) the resident is coded as requiring a mechanically altered diet (requires change in texture of food or liquids, e.g. pureed food, thickened liquids). Speech Therapy Treatment Encounter note dated [DATE] at 5:42 PM, showed regular nectar thin liquids presented mild cues for head posture chin down during liquid intake. The Nurse's Note dated (MONTH) 17, (YEAR), at 11:15 PM showed that Resident #158 was in the Day Room with other residents eating a steak and cheese sub from a local carry out when a staff member yelled for help at about 9:40 PM. Upon entering the Day Room, the nurse observed the resident sitting in his wheelchair coughing/choking and his eyes rolling backward. The nurse called for help and performed five (5) back blows on each shoulder blades. Resident #158 coughing increased. In addition, the Nurse's Note showed abdominal thrusts were performed three (3) times but the resident condition is not improved. He went into code and CPR (Cardiopulmonary Resuscitation) was initiated and 911 was called, resident was intubated and then transferred to (Hospital Name). Further review of the medical record showed an eInteract Change of Condition Evaluation Form dated (MONTH) 17, (YEAR), at 9:59 PM. The form showed Resident #158's [DIAGNOSES REDACTED]. The most recent vital signs recorded as [DATE] at 9:40 AM- ,[DATE], pulse- 78 beats per minutes, respirations- 20 breaths per minutes, and the most recent temperature recorded as 98.4 degree Fahrenheit orally at 2:28 PM on (MONTH) 17, (YEAR). The most recent oxygen saturation recorded as 98% (percent) on (MONTH) 16, (YEAR) at 11:03 PM. The physical assessment showed Resident #158 had no observed neurological changes but was also unresponsive, and choking. Under section summarize your observations and evaluation: Resident was eating outside food steak and cheese sandwich when he began choking. The interventions documented were 911 was called and CPR continued, resident was transported via 911. During a face-to-face interview on [DATE] with Employee #26 at 4:21 PM regarding the resident change in condition, I completed the Nursing Home to Hospital Transfer Form on [DATE] and I assisted with CPR (cardiopulmonary resuscitation) for Resident# 158. When I came in the dayroom I saw the resident trying to stick his hand down his throat , we (staff) were trying to get him to stand and he could not stand he was conscious and I was telling him to cough and Employee# 25 did the back slaps over his shoulder blades, he had cup of water he was trying to drink it and it was coming out of his mouth, then he could not breathe he was shaking and he became stiff and he was not breathing and we started CPR we called a code and 911, the supervisor (Employee# 27) came to the floor and took over CPR. During a telephone interview on [DATE] at 5:35 PM, Employee# 24, stated I was in the dayroom but I was not assigned to the resident and three residents came in with food from the outside; Resident#158 and two other residents. I was not too far away and he asked for sips of water, thickened water. While they were eating I gave him the thickened water and then I asked him if he was choking. He said yes, he only took a few bites before he started choking. It was not a long time at all, if ten minutes, before he started choking. He had a lot of sandwich left. I saw staff in the hall way and called for help they came in and started working on him. During a face-to-face interview with Employee #27 on [DATE] at 5:00 PM, they called a medical emergency and I came from the first floor and I met the Resident# 158 holding his throat he said that he just choked he stood up and we supported him I did the [MEDICATION NAME] Maneuver and then we placed him on the floor and I took over CPR, oxygen and suction with a Yankeur (oral suction tool), by now 911 had arrived and his SP02 (oxygen level) was 62% they (911) took over chest compressions with an automatic chest compression system they (staff) pulled out a big piece of meat, he was alive when he left the floor he was to go (hospital name) but he went to (hospital name). Review of the facility policy titled Serenity Rapid Response Team dated (MONTH) 27, (YEAR), showed that staff are to respond to all emergencies to include a licensed nurse from each unit and the Director of Nursing/Nursing Supervisor, and Nurse Practitioner , if available. The Director of Nursing/Nursing Supervisor is responsible for bringing the AED (Automated External Defibrillator). Review of the American Heart Association Guidelines (YEAR)/ CPR & ECC for Choking Relief in a Responsive Adult includes positioning self behind the choking victim and wrap arms around the victim's midsection and search for their bellybutton. Make a fist with one hand and grasp it with the other hand and thrust both hands inward and upward, until the blockage comes out. If the patient loses consciousness and the blockage remains, lower the patient to the floor. Open the mouth with the head tilt/ chin lift and look inside for the item and begin chest compressions. Reassess for expelled object and pulse until paramedics arrive. The facility failed to show all interventions implemented to include complete vital signs, administration of oxygen, suctioning, the performance of a comprehensive assessment, cardiovascular assessment, respiratory assessment, and neurological assessment at and during the change of condition. In addition, review of the interventions provided during the choking episode showed the interventions taken were inconsistent with acceptable professional standards for care of choking resident. During a face-to face-interview on (MONTH) 20, (YEAR), Employee #1 and 2 acknowledged the findings.",2020-09-01
75,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,756,E,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview of three (3) of 56 sampled residents, the physician failed to document the review of the pharmacist recommendations and document the action to be taken or not taken to address the recommendation for one (1) resident receiving blood pressure medication; one (1) resident receiving an antibiotic and iron supplement; and one (1) resident receiving a blood thinner and antacid. Residents' # 38, #104 and #138. Findings included . 1. The attending physician failed to document review of the pharmacist recommendation to check pulse pre the administration of [MEDICATION NAME] at 9 am for Resident #38. Resident #38 was admitted to the facility on (MONTH) 24, 2005, with [DIAGNOSES REDACTED]. Review of the Medication Regimen Review dated (MONTH) 3, (YEAR), showed recommendation for pulse check with the administration of the 9AM dose of [MEDICATION NAME]. A review of the May, June, and (MONTH) (YEAR) Medication Administration Records showed [MEDICATION NAME] tablet 10MG ([MEDICATION NAME]) one tablet given by mouth one time a day for Hypertension with blood pressure record. However, the Medication Administration Records for May, June, and (MONTH) 201,8 does not contain documentation of the pulse rate. A review of the physician progress notes [REDACTED]. During a face-to-face interview on (MONTH) 20, (YEAR), Employee #19 reviewed the record and acknowledged the findings. 2. The attending physician failed to document review of the pharmacist recommendation to [MEDICATION NAME] Iron two hour apart; and to establish a stop date for the administration of [MEDICATION NAME] for Resident #104. Resident #104 was admitted to the facility on (MONTH) 10, (YEAR), with [DIAGNOSES REDACTED]. A review of the Drug Regimen Review record showed pharmacist recommendation as follows: On (MONTH) 24, (YEAR), the pharmacist asked the physician to consider an end date for [MEDICATION NAME] and separating the administration [MEDICATION NAME] Iron by two (2) hours. On (MONTH) 24, (YEAR), the pharmacist again asked the physician to consider separating the administration [MEDICATION NAME] Iron by two hours as well as [MEDICATION NAME]. On (MONTH) 26, (YEAR), the pharmacist again asked the physician to consider separating the administration [MEDICATION NAME] Iron by two hours. Review of the physician orders [REDACTED].#104 continued to receive [MEDICATION NAME] 80 milligrams once a day, without an end date documented, [MEDICATION NAME] milligrams two (2) times daily at 9AM and 9 PM and Iron 325 milligrams once daily at 9 AM. A review of the physician progress notes [REDACTED]. During a face-to-face interview on (MONTH) 20, (YEAR), Employee #19 reviewed the record and acknowledged the findings. 3. The attending physician failed to document the review of the pharmacist recommendations and document the action to be taken or not taken to address the recommendation to schedule [MEDICATION NAME] at bedtime for Resident #138. Resident #138 was admitted to the facility on (MONTH) 6, (YEAR), with [DIAGNOSES REDACTED]. A review of the Drug Regimen Review records showed the pharmacist recommendations as follows: On (MONTH) 24, (YEAR), the pharmacist suggest changing [MEDICATION NAME] administration time to bedtime. On (MONTH) 24, (YEAR), the pharmacist questioned if [MEDICATION NAME] could be reduced. On (MONTH) 26, (YEAR), the pharmacist suggested changing [MEDICATION NAME] administration time to bedtime Review of the Medication Administration Record [REDACTED]. A review of the physician progress notes [REDACTED]. During a face-to-face interview on (MONTH) 20, (YEAR), Employee #19 reviewed the record and acknowledged the findings.",2020-09-01
76,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,758,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 56 sampled residents, the physician failed to respond to the pharmacist's recommendation to evaluate Resident #65's use of [MEDICATION NAME] with a [DIAGNOSES REDACTED]. Findings included . The physician failed to acknowledge and/or respond to the pharmacist's recommendation for the resident's use of the following medications: [REDACTED]. Resident #65. Resident #65 was admitted to the facility on (MONTH) 2, (YEAR), with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The pharmacist reviewed the resident's medications and made the following recommendations to the physician: On (MONTH) 3, (YEAR), Suggest PRN (as needed) [MEDICATION NAME] include an end date. On (MONTH) 24, (YEAR) ,Please eval (evaluate) [MEDICATION NAME] (with) Dementia dx (diagnosis) On (MONTH) 26, (YEAR), Please evaluate PRN [MEDICATION NAME] per CMS 14 day regulation; and Vitamin D Level suggested with 50,000 Units ordered weekly. The Consultant Pharmacist Inspection Report form contains the pharmacist's recommendation, three boxes (Agree), (Disagree) and (Other), designated for the Physician/Prescriber's response, an area for comment(s) and an area for the physician's signature and date to indicate when the form was signed. The form was left blank in all the designated areas. In addition, review of the physician's total plan of care failed to show any evidence that the physician acknowledged and/or responded to the pharmacist's recommendation. A face-to-face interview was held with Employee #2 at approximately 11:00 AM on (MONTH) 16, (YEAR). The employee was asked about the process for reviewing the MRR forms. The employee stated that the forms are placed on the residents' charts. The physicians usually review the recommendations, check the appropriate responses and sign the forms to respond and acknowledge receipt of the recommendations. The physician failed to acknowledge and/or respond to the pharmacist's recommendation to evaluate Resident # 65's use of [MEDICATION NAME] and Vitamin D. Employee #5 acknowledged the finding.",2020-09-01
77,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,773,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, the facility faied to obtain a urine analysis, culture and sensitivity as per the nurse practitioners recommendation for one (1) resident, and failed to ensure one (1) resident's lab work was completed in accordance to the physician orders [REDACTED].#1 and #44). Findings include: Facility staff failed to obtain a urine analysis and culture and sensitivity as per the nurse practitioners recommendation for Resident #1. Resident #1 was readmitted to the facility on (MONTH) 13, (YEAR), with [DIAGNOSES REDACTED]. In addition, the resident has a suprapubic catheter in place. The Health Status note dated (MONTH) 12, (YEAR), at 10:55 AM read, Asked to resident's medication list due to repeated falls .[NAME] known dementia with repeated falls due to? H/o (history of) UTI (urinary tract infection) - SP (status [REDACTED]. P (plan).Check UA (urinalysis) and urine C/S (culture and sensitivity in AM for F/U (follow up) UTI. A review of the clinical record lacked evidence that the urinalysis and the culture and sensitivity of the resident's urine was completed as recommended by the Nurse Practitioner. During a face-to-face interview with Employee #5 on (MONTH) 17, (YEAR), at approximately 3:00 PM, she acknowledged the urinalysis and urine culture was note done. 2. Facility staff failed to ensure that Resident #44's lab work was completed in accordance with the physician's orders [REDACTED].>Resident #44 admitted on (MONTH) 26, (YEAR), with a [DIAGNOSES REDACTED]. A review of Physician orders [REDACTED]. (2) UA(urinalysis & (and) Urine C/S (culture /sensitivity) by I/O (in/out) Cath (catheter) on 2/17/18 AM Dx (diagnoses) R/O (rule/out) UTI (urinary tract infection). A review of the Clinical Records showed that the Resident had no labs drawn to be reported on since his admission to the facility (MONTH) 26, (YEAR), to (MONTH) 19, (YEAR), indicating the labs were not done. A review of the Nurses Progress Note dated (MONTH) 16, (YEAR), called responsible party to inform her of worsening UE (upper extremities) weakness and lab work ordered by NP (nurse practitioner). Responsible Party stated her needs to speak with NP (nurse practitioner) before the lab work is to be done . NP and notified her of Responsible party request to speak with her before the lab work is to be done. The evidence show facility staff failed to contact the (Hospital Name) lab and transport Resident #44 for CBC (complete blood count), CMP (comprehensive metabolic panel), Magnesium level, TSH, Free T4, Phosphorous level, Vit (vitamin) B12, Folate level, UA & C/S to ensure lab work was completed. A face-to-face interview conducted on (MONTH) 19, (YEAR), at 10:00 AM with Employee #19. She stated RP refused facility doing blood work only what she gave permission for, the resident must go to the (Outside hospital). She acknowledges the findings The labs were not done.",2020-09-01
78,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,812,F,0,1,L7I811,"Based on observations and staff interview, the facility failed to prepare, distribute and serve foods under sanitary conditions as evidenced by greasy hood baffles over the grease fryer, expired milk on 42 of 91 observations, staff failure to wear gloves while handling utensils, staff failure to wear a beard net on the tray line, two (2) of three (3) soiled air curtains from the dishwashing machine, undocumented dishwashing machine temperatures, and failure of staff to correctly articulate critical dishwashing machine wash and rinse temperatures. Findings included . During observations and record review on (MONTH) 10, (YEAR), at approximately 9:30 AM: 1. Dust and grease were visible on three (3) hood baffles located above the fryer. 2. Forty-two (42) of 91 half-pint containers of regular milk were expired as of (MONTH) 8, (YEAR). 3. Dietary staff setting up resident trays during the lunch period on (MONTH) 10, (YEAR), at approximately 12:30 PM, failed to wear gloves and touched exposed and unwrapped plastic utensils such as forks and spoons with bare hands. 4. Dietary staff with beard failed to wear a beard net while serving foods from the tray line on (MONTH) 10, (YEAR), at approximately 12:30 PM. 5. Food temperatures from the tray line were not recorded on (MONTH) 9, (YEAR). 6. Cold food temperatures were not adequately maintained on (MONTH) 13, (YEAR), at approximately 1:52 PM as cold food such as chicken salad was tested at 54.5 degrees Fahrenheit. 7. Two (2) of three (3) air curtains from the dishwashing machine were soiled. 8. A review of the Dishwashing/Warewashing Machine Temperature Log on (MONTH) 10, (YEAR), at approximately 12:30 PM, revealed that wash and rinse (final) temperatures were inconsistently recorded. Dishwashing machine temperatures for the month of (MONTH) (YEAR), were not documented for 18 of 31 days. Dishwashing machine temperatures for the month of (MONTH) (YEAR), were not documented for 19 of 30 days. Dishwashing machine temperatures for the month of (MONTH) (YEAR), were not documented for 9 of 10 days. 9. Dietary staff failed to correctly articulate Wash and Rinse Dishwashing machine temperatures on (MONTH) 10, (YEAR), between 11:45 AM and 12:07 PM. Dishwashing machine wash and rinse (final) temperatures were observed to be below 150 degrees Fahrenheit and 180 degrees Fahrenheit respectively between 10:10 AM and 11:02 AM on (MONTH) 10, (YEAR). Those temperatures were not recorded on the morning of (MONTH) 10, (YEAR). A face-to-face interview was conducted with dietary staff members (4) assigned to dishwashing duties on the morning of (MONTH) 10, (YEAR). One employee stated that she turns the machine on at approximately 10:30 AM to start cleaning dishes but did not check the dishwashing machine temperatures at all the morning of (MONTH) 10, (YEAR). Another employee is new (April (YEAR)) and has not been assigned or trained to observe and monitor dishwashing machine temperatures. The third employee stated that the wash temperature should be 365 degrees Fahrenheit and the rinse temperature should be 398 degrees Fahrenheit. The fourth employee stated that the wash temperature should be greater than 180 degrees Fahrenheit and the rinse temperature less than 160 degrees Fahrenheit. During a face-to-face interview on (MONTH) 17, (YEAR), Employee #10 and/or Employee #11 acknowledged these findings.",2020-09-01
79,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,865,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview the facility failed to develop and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failing to implement systems to correct identified problems within the facility and anticipate potential problems and develop interventions to prevent their occurrence. Findings included . During the interview on (MONTH) 20, (YEAR), at approximately 2:00 PM, a review of the facility ' s quality assurance and performance improvement (QAPI) program conducted with Employees #1 and 6. The review of the program showed the facility failed to identify concerns, and develop and implement actions plans to correct identified areas of deficient practice in the following areas: The facility failed to implement a Dementia Program to provide person-centered care for residents with the [DIAGNOSES REDACTED]. Failed to establish a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Failed to provide policies and procedures related to water management to inhibit the growth and spread of Legionella. Failed to develop a risk assessment system to identify sites where waterborne pathogens such as Legionella could grow and spread. Failed to implement a water management program to test for, monitor and control Legionella and other waterborne pathogens. The facility failed to provide an environment that was free of pests Failed to implement a system for monitoring the dish machine Employees # 1 and 6 were made aware of the findings at the time of the interview.",2020-09-01
80,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,880,F,0,1,L7I811,"Based on observations and staff interview, the facility failed to maintain laundry equipment in safe condition as evidenced by two (2) of three (3) washing machines in the laundry room that continuously leaked through their access door. Facility staff failed to develop policies and procedures to identify, monitor and manage the growth and spread of bacteria such as Legionella in their water system, and failed to establish a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Findings included . 1.During observations in the laundry room on (MONTH) 11, (YEAR), at 3:10 PM, two (2) of three (3) washing machines were steadily leaking through the bottom of the access door. During a face-to-face interview on (MONTH) 17, (YEAR), Employee #13 acknowledged these findings. 2.Facility staff failed to develop policies and procedures to identify, monitor and manage the growth and spread of bacteria such as Legionella in their water system. The facility did not have available policies and procedures related to water management to inhibit the growth and spread of Legionella. The facility lacked a risk assessment to identify where waterborne pathogens such as legionella could grow and spread. The facility failed to test and implement a water management program to test for, monitor and control Legionella and other waterborne pathogens. During a face-to-face interview on (MONTH) 18, (YEAR), at 9:20 AM, Employee #12 confirmed the findings. 3. Failed to establish a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. On (MONTH) 19, (YEAR), at approxiately 2:30 PM, a review the faciltiy's infection control program was conducted. At this time, it was noted that surveillance data related to infection control for (MONTH) and (MONTH) (YEAR), was not used for staff education to help minimize the spread of the infection (e.g., staff education and competency assessment). During a face-to-face interview with Employee #2 on (MONTH) 19, (YEAR), at approxiately 2:30 PM, she acknowledged the findings.",2020-09-01
81,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,908,E,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to provide an environment free from accident hazards as evidenced by several remote bed controllers cords that were frayed in six (6) of 34 resident rooms. The facility also failed to maintain essential equipment in safe condition as evidenced by one (1) of one (1) high temperature dishwashing machine that failed to reach a minimum final rinse temperature of 180 degrees Fahrenheit and two (2) of three (3) washing machines that were leaking in the laundry room. Findings included . 1.The facility failed to provide an environment free from accident hazards as evidenced by several remote bed controllers cords that were frayed in six (6) of 34 resident rooms. During observations throughout the facility on (MONTH) 11, (YEAR), between 11:15 AM and 3:00 PM, remote bed controller electrical cords were frayed in resident room [ROOM NUMBER] (A and B beds), 131, 222B, 229A, 313 (A and B beds), 322A, six (6) of 34 resident's rooms surveyed. The uncovered, exposed electrical wires created a potential electrical shock hazard to residents, staff and the public. During a face-to-face interview on (MONTH) 11, (YEAR), Employee #12 acknowledged these findings at the time of observation. 2.The facility failed to maintain one (1) of one (1) high temperature dishwashing machine that failed to reach a minimum final rinse temperature of 180 degrees Fahrenheit. The high-temperature Dishwashing machine failed to reach a minimum of 180 degrees Fahrenheit between 10:10 AM and 11:02 AM on (MONTH) 10, (YEAR), when staff was in the process of cleaning trays, dishes, bowls and utensils that were used for breakfast. Facility used paper plates and plastic utensils for lunch and dinner meals on (MONTH) 10, (YEAR). During a face-to-face interview on (MONTH) 17, (YEAR), Employee #10 and/or Employee #11 acknowledged these findings. 3. Facility staff failed to ensure that two (2) of three (3) washing machines were in operating condition in the laundry room. During observations in the laundry room on (MONTH) 11, (YEAR), at 3:10 PM, two (2) of three (3) washing machines were steadily leaking through the bottom of the access door. During a face-to-face interview on (MONTH) 17, (YEAR), at approximately 4:30 PM, Employee #13 acknowledged these findings.",2020-09-01
82,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,919,D,0,1,L7I811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, the facility failed to maintain the call bell system in good working condition as evidenced by call bells in two (2) of 34 resident rooms that failed to alarm when tested and a call bell without a pull cord in one (1) of 34 resident rooms. Findings included . During observations on the second and third-floor nursing units on (MONTH) 11, (YEAR), between 11:15 AM and 2:35 PM, call bells in two (2) of 34 resident rooms (#210 and #330), did not alarm when activated. Also, the pull cord from the call bell located in the bathroom of resident room [ROOM NUMBER] one (1) of 34 resident rooms was missing. A breakdown in the communication system could prevent or delay the resident, staff or the public from alerting staff. During a face-to-face interview on (MONTH) 11, (YEAR), Employee #12 acknowledged these findings at the time of observation.",2020-09-01
83,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-07-20,925,F,0,1,L7I811,"Based on observations the facility failed to maintain an effective pest control program as evidenced by flying pests seen in the main kitchen from (MONTH) 10, (YEAR), through (MONTH) 19, (YEAR). Findings included . Numerous flying insects were observed throughout the facility during the survey period from (MONTH) 10, (YEAR), through (MONTH) 19, (YEAR), in several areas including the main kitchen, the first, second and third floor nursing units. During a face-to-face interview on (MONTH) 17, (YEAR), Employee #10 and/or Employee #11 acknowledged these findings.",2020-09-01
84,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2019-08-02,623,D,1,0,PMO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review for Resident #1, one (1) of six (6) residents reviewed, it was determined that facility staff failed to notify DOH and the Responsible Party. The findings include: According to a nurse's note dated (MONTH) 31, 2019 at 12:14 PM: .RP called 911 and resident was transferred to (hospital) . There was no evidence that the resident returned to the facility. The resident's record and state data base were searched but no transfer form was found. Employee #1 was asked on (MONTH) 2, 2019, for a copy of the transfer form. He/she reported no form was found. There was no transfer form submitted to DOH for the (MONTH) 31, 2019 transfer. According to the Discharge/Death Summary that was completed by the physician on (MONTH) 26, 2019, with a discharge date of (MONTH) 18, 2019 as follows: This is an elderly [AGE] year old female who was admitted with above and (unable to read) and Stage IV [MEDICAL CONDITION] terminal illness .resident was sent to acute care hospital ED following alleged fall in her room. Resident was sent to hospital in no apparent distress. The resident's record and state data base were searched but no discharge form was found. Employee #1 was asked for a copy of the discharge form. He/she reported no form was found. There was no discharge form submitted to DOH for the (MONTH) 18, 2019 discharge. The facility failed to send a transfer form on (MONTH) 30, 2019 when Resident #1 was sent to the hospital and a discharge form dated (MONTH) 18, 2019, when the resident failed to return to the facility. Employee #1 acknowledged the above information on (MONTH) 2, 2019. The record was reviewed on (MONTH) 2, 2019.",2020-09-01
85,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,247,D,0,1,GZ9J11,"Based on record review, resident and staff interview for one (1) of 35 Stage 2 sampled residents, it was determined that facility staff failed to provide notice to Resident #158 prior to a roommate change. The findings include: A resident interview was conducted on (MONTH) 15, (YEAR) at approximately 10:30 AM. A query was made regarding Have you been moved to a different room or had a roommate change in the last nine (9) months? the resident responded yes and that (he/she) was not given notice when the roommate change occurred. A review of the clinical record for Resident #158 lacked documentation that the resident was provided notice before he/she received a new roommate on (MONTH) 2, (YEAR). A face-to-face interview was conducted on (MONTH) 18, (YEAR) with Employee #7 at approximately 9:30 AM. He/she revealed that the process is that the resident or responsible party is notified prior to roommate changes and that it is documented in the medical record by Social Workers and if it occurs when they are not present the nursing staff will document. A face-to-face interview was conducted with Employee #4 on (MONTH) 18, (YEAR) at approximately 12:00 PM. When queried, the employee acknowledged that the resident was not informed prior to his/her roommate being changed. The record was reviewed on (MONTH) 18, (YEAR).",2020-09-01
86,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,253,E,0,1,GZ9J11,"Based on observations made on (MONTH) 16, (YEAR) at approximately 3:00 PM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary environment as evidenced by loose privacy curtains in five (5) of 37 residents' rooms, dusty exhaust vents in three (3) of 37 residents' rooms, soiled shower floors in one (1) of three shower rooms and one (1) of three clinical sink hopper in the facility that failed to flush when tested . The findings include: 1. Privacy curtains were detached and hanging off the hooks in five (5) of 37 resident rooms including rooms #143, 227, 242, 319 and #341. 2. Bathroom exhaust vents were soiled with dust in three (3) of 37 resident rooms (#108, 307 and 319). 3. The floor to one (1) of three (3) shower rooms in the facility was soiled. 4. A clinical sink hopper located in the soiled utility room on the third floor failed to flush and was not functioning as intended, one (1) of three (3) clinical sink hoppers in the facility. These observations were made in the presence of Employee #15 who confirmed the findings.",2020-09-01
87,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,279,D,0,1,GZ9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 35 Stage 2 sampled residents, it was determined that facility staff failed to initiate a care plan with goals and approaches to address one (1) resident ' s impaired vision and one (1) resident's behavioral symptoms. Residents #39 and #160. The findings include: 1. Facility staff failed to initiate a care plan with goals and approaches for Resident #39 who had impaired vision and was diagnosed with [REDACTED]. A review of an Eye Exam Consultation Record dated (MONTH) 28, (YEAR) revealed the following [DIAGNOSES REDACTED]. A review of the Annual MDS (Minimum Data Set) dated (MONTH) 9, (YEAR) revealed that Resident #39 in Section B1000 Vision is coded as Impaired . Section V, Care Area Assessment Summary revealed in care area #4 Visual Function that a check mark was placed in the boxes allocated for Care Area triggered and Care planning decision indicating care plan needed. A review of the clinical record lacked evidence of a care plan with goals and approaches to address Resident #39's impaired vision. A face-to-face interview was conducted on (MONTH) 17, (YEAR) at approximately 11:05 AM with Employee #4 who acknowledged the aforementioned findings. The record was reviewed on (MONTH) 17, (YEAR). 2. Facility staff failed to initiate a care plan with goals and approaches to address Resident #160's behavioral symptoms. A history and physical examination [REDACTED]. Neurological: Poor, uncooperative (with) exam . An admission MDS (Minimum Data Set) dated (MONTH) 26, (YEAR) revealed Section E0800 Behavioral Symptoms (rejection of care) was one of the triggered care areas to be addressed in the care plan. A review of Resident #160 ' s comprehensive care plan lacked evidence of a care plan with goals and approaches to address the resident ' s behavioral symptoms. A face-to-face interview was conducted with Employee #3 on (MONTH) 17, (YEAR) at approximately 11:20 AM. After review of the aforementioned he/she acknowledged the findings. The clinical record was reviewed on (MONTH) 17, (YEAR).",2020-09-01
88,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,280,D,0,1,GZ9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 35 Stage 2 sampled residents, it was determined that facility staff failed to review and revise Resident #95's care plan to reflect an integrated approach with the participation of hospice, the facility, and the resident or representative. Resident #195. The findings include: A review of the physician's orders [REDACTED]. Hospice start date (November 13, (YEAR)). A review of Resident #95's care plan revealed a care plan for Resident has a terminal prognosis r/t (related/to) ([DIAGNOSES REDACTED]. However, the care plan lacked specific identification of the disciplines and/or team (hospice vs. nursing home) responsible for implementing the interventions of the hospice care plan. A face-to-face interview was conducted on (MONTH) 16, (YEAR) with Employee #4. After review of the aforementioned he/she acknowledged the findings.",2020-09-01
89,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,281,D,0,1,GZ9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 35 Stage 2 sampled residents, it was determined that facility staff failed to follow acceptable standards of practice for administering an oral aerosol inhalation treatment per the manufacturer ' s specifications. Resident #109. The findings include: According to Glaxo[NAME]Kline Company-www.[MEDICATION NAME].com ; Revised (MONTH) (YEAR)- pp 33-35; stipulates: How to use your [MEDICATION NAME] HFA inhaler . Step 2. Hold the inhaler with the mouthpiece down (canister should be pointed upward) . On (MONTH) 11, (YEAR) at approximately 10:10 AM, Employee #18 was observed administering an oral inhalation aerosol treatment to Resident #109. Employee #18 instructed the resident to take a deep breath in and out. Proceeded to position the mouthpiece of the inhaler in the resident's mouth in an upward position (canister was pointed downward). A face-to-face interview was conducted with Resident #109 after the medication was administered. A query was made, if he/she felt the effect of the medication? He/she responded, Yes, I felt it going down. A face-to-face interview was conducted with Employee #18. He/she was queried regarding the correct positioning of the mouthpiece of the inhaler in the resident's mouth. He/she stated, It should be positioned with the mouthpiece in the down position with the canister pointing up. That's the way I usually administer it. The observation and record review were conducted on (MONTH) 11, (YEAR). Crossed Referenced 483.25 (F309)",2020-09-01
90,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,309,D,0,1,GZ9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for two (2) of 35 Stage 2 sampled residents, it was determined that facility staff failed to clarify physician's orders [REDACTED]. for one (1) resident; and failed to follow through on an Infectious Disease (ID) appointment for one (1) resident. Residents' #109 and #160. The findings include: According to Glaxo[NAME]Kline Company-www.[MEDICATION NAME].com ; Revised (MONTH) (YEAR)- pp 33-35; stipulates: How to use your [MEDICATION NAME] HFA inhaler . Step 2. Hold the inhaler with the mouthpiece down (canister should be pointed upward) . Step 7. Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it . 1a. Facility staff failed to clarify physician's orders [REDACTED].#109's mouth following an oral aerosol inhalation treatment. On (MONTH) 11, (YEAR) at approximately 10:10 AM, Employee #18 was observed administering an oral inhalation aerosol to Resident #109. Resident #109 had a physician's orders [REDACTED].) The employee administered Resident #109 one (1) puff from the [MEDICATION NAME] inhaler. After administering the inhaler, the employee did not instruct the resident to rinse his/her mouth with water. A face-to-face interview was conducted with Employee #18 at approximately 10:00 AM. He/she was queried regarding not having the resident rinse with water and spit after administering the [MEDICATION NAME]. He/she replied, that since the resident is on aspiration precautions, (she/he) is not instructed to rinse with water because of the possibility of the resident swallowing it. Facility staff failed to clarify physician's orders [REDACTED].#109's mouth following an oral aerosol inhalation treatment. The observation and record review were conducted on (MONTH) 11, (YEAR). 1b. Facility staff failed to administer an oral aerosol inhalation treatment per the manufacturer ' s specification. Resident #109 On (MONTH) 11, (YEAR) at approximately 10:10 AM, Employee #18 was observed administering an oral inhalation aerosol treatment to Resident #109. Resident #109 had a physician's orders [REDACTED]. Employee #18 instructed the resident to take a deep breath in and out. Proceeded to position the mouthpiece of the inhaler in the resident's mouth in an upward position (with the canister pointed downward). A face-to-face interview was conducted with Resident #109 after the medication was administered. A query was made, if he/se felt the effect of the medication? He/she responded, Yes, I felt it going down. A face-to-face interview was conducted with Employee #18. He/she was queried regarding the correct positioning of the mouthpiece of the inhaler in the resident's mouth. He/she stated, It should be positioned with the mouthpiece in the down position(with the canister in the upward position). That's the way I usually administer it. The observation and record review were conducted on (MONTH) 11, (YEAR). 2. Facility staff failed to follow through on an infectious disease appointment for Resident #160. A history and physical examination [REDACTED]. The physician's orders [REDACTED]. A review of the (MONTH) 8, (YEAR) pharmacy consultation report read: (Resident ' s name) receives [MEDICAL CONDITION] therapy, Abacavir, [MEDICATION NAME], Kaletra The following monitoring plan for [MEDICAL CONDITION] therapy is recommended (1) continuous therapy: CD4 count and [MEDICAL CONDITION] load . Physician ' s response: I accept the recommendations(s) with the following modifications: Patient with ID (Infectious Disease) (follow-up). Will (check) ID notes. Follow up ID on (MONTH) 22, (YEAR). An infectious disease consult dated: (MONTH) 8, (YEAR) revealed: Plan: RTC (Return to clinic) - 2 weeks . According to a nurse ' s note dated (MONTH) 28, (YEAR) -1446 (2:46 PM)- F/U with infectious disease on (MONTH) 28, (YEAR) with (MD named) . Appointment rescheduled . A review of the medical record lacked evidence that the facility followed through on the infectious disease recommendation to return in two (2) weeks. A face-to-face interview was conducted with Employee #3 regarding the resident ' s follow-up ID appointment. He/she acknowledged the findings. The clinical record was reviewed on (MONTH) 17, (YEAR).",2020-09-01
91,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,323,D,0,1,GZ9J11,"Based on observations made on (MONTH) 16, (YEAR) at approximately 3:00 PM, it was determined that the facility failed to ensure that resident's environment remain free of accident hazards as evidenced by a missing light cover in the bathroom of one (1) of 37 resident's rooms surveyed. The findings include: The cover to the ceiling light in the bathroom of resident room #307 was missing and its electrical wires were exposed and accessible to residents, staff and/or the public, in one (1) of 37 resident's rooms surveyed. These observations were made in the presence of Employee #15 who acknowledged findings.",2020-09-01
92,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,371,D,0,1,GZ9J11,"Based on observations made on (MONTH) 16, (YEAR) at approximately 9:30 AM, it was determined that the facility failed to serve foods under sanitary conditions as evidenced by four (4) of 16 soiled steam table wells in the facility. The findings include: Steam table wells located on the second floor dining room were soiled with leftover food residue, four (4) of 16 steam table wells surveyed. These observations were made in the presence of Employee #14 who acknowledged the findings.",2020-09-01
93,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,386,D,0,1,GZ9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 35 Stage 2 sampled residents , it was determined that the physician failed to follow through on one (1) resident ' s diagnostic test. Resident #45. The findings include: An interim physician's order dated (MONTH) 4, (YEAR) at 12:20 PM directed: Psychiatry- F/U (Follow-up) for Resident ' s [MEDICATION NAME] (secondary to) elevated prolactin level (hormone level made by the pituary gland)- 38.23 (high); ( normal range-1.8-20.3) done on 12/21/15. A review of the clinical record revealed: Report of Consultation (not dated), From: (Attending physician named), Report requested regarding: Psychiatry (follow-up) for resident ' s [MEDICATION NAME] use secondary to elevated prolactin level 38.23 (1.8-20.3) done on 12/21/15; Report: Findings: Will see today 1/11/16 . (psychiatry signature) . A review of the psychiatry notes revealed the following: December 28, (YEAR)- . Axis I- [MEDICAL CONDITION] -[MEDICATION NAME] 150mg po bid for mood stabilization, Follow up in 2 weeks January 19, (YEAR)- .Axis I: [MEDICAL CONDITION]- Continue current treatment, Follow up in (a) month March 28, (YEAR)- . Axis I: [MEDICAL CONDITION]- Continue current treatment, Follow up in a month June 13, (YEAR) . Axis I: [MEDICAL CONDITION], continue current treatment, Follow up in one month . A review of the attending physician ' s notes from (MONTH) (YEAR) to (MONTH) (YEAR) revealed no documentation regarding the resident ' s elevated prolactin level. There was no evidence in the clinical record that the attending and psychiatric physician followed up to review the status of the elevated prolactin level. A face-to-face interview was conducted with Employees #5 and #19 on (MONTH) 17, (YEAR) at approximately 11:20 AM regarding the aforementioned findings. Both acknowledged the findings. Employee #19 stated he/she will follow-up. The clinical record was reviewed on (MONTH) 17, (YEAR).",2020-09-01
94,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,431,D,0,1,GZ9J11,"Based on observation, record review, and staff interviews, it was determined that the facility staff failed to remove one (1) resident ' s expired medications from the 2nd floor medication cart. The findings include: On (MONTH) 18, (YEAR) at approximately 1:40 PM the medication storage observations revealed the following: Resident #176 had one (1) blister packet with a total of 21 Zolpidem 5mg tablets. The expiration date on the blister packet was (MONTH) 31, (YEAR). The resident last received the medication on (MONTH) 9, (YEAR) at 11:35 PM. The observation was made in the presence of Employee #16. He/she acknowledged the findings.",2020-09-01
95,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,456,D,0,1,GZ9J11,"Based on observations made on (MONTH) 11, (YEAR) at approximately 9:15 AM, it was determined that the facility failed to maintain essential equipment in good working condition as evidenced by one (1) of four (4) broken burner grates from the gas stove, two (2) of eight (8) steam wells covers with a missing handle, a malfunctioning temperature gauge and power light from one (1) of one (1) reach-in refrigerator, and a torn air curtain in the walk-in freezer. The findings include: 1. One (1) of four (4) burner grates from the gas stove in the main kitchen was broken and part of it was missing. 2. One (1) of four (4) steam table well lid from the steam table in the main dining room and one (1) of four (4) steam table well lid from the steam table on the third floor were missing a handle. 3. The built-in thermometer and the power light from one (1) of one (1) reach-in/prep refrigerator in the main kitchen were out of service. 4. One (1) of seven (7) air curtains from one (1) of one (1) walk-in freezer was torn. These observations were made in the presence of Employee #14 who confirmed the findings.",2020-09-01
96,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,463,D,0,1,GZ9J11,"Based on observations made on (MONTH) 16, (YEAR) at approximately 3:00 PM, it was determined that the facility failed to maintain call bells in good working condition as evidenced by a call bell that failed to alarm when tested in one (1) of 37 resident ' s rooms and one (1) of three (3) call bells in the shower room on the third floor that lacked a pull cord. The findings include: 1. The call bell in resident room #126, one (1) of 37 resident ' s rooms did not initiate an alarm when tested . 2. One (1) of three call bells in the shower room on the third floor was missing a pull cord. These observations were made in the presence of Employee #15 who confirmed the findings.",2020-09-01
97,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2016-08-18,514,D,0,1,GZ9J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 35 Stage 2 sampled residents, it was determined that facility staff failed to ensure that one (1) residents medical record was inclusive of the resident's Hospice documents. Resident #195. The findings include: A review of the physician's orders [REDACTED]. Hospice start date (November 13, (YEAR).) After further review of the medical record there was no evidence that the hospice Initial Nursing Assessment, and the Physician ' s Plan of Care were readily accessible on the active clinical record. A face-to-face interview was conducted on (MONTH) 16, (YEAR) with Employee #4. After review of the aforementioned he/she acknowledged the findings and had the documents faxed to the facility. The record was reviewed on (MONTH) 16, (YEAR).",2020-09-01
98,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-10-23,636,D,1,0,FXOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, it was determined that facility staff failed to accurately code the MDS for active diseases and bed mobility for one (1) of three (3) residents reviewed. Resident #1. The findings include: Resident #1 was admitted to the facility on (MONTH) 11, (YEAR). According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 19, (YEAR), Resident #1 scored 9/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14 a score of 8-12 suggests the resident has moderately impaired cognitive skills for daily decision making. Resident #1 was assessed as requiring extensive assistance with two person assist for all Activities of Daily Living (ADLs) in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Resident #1 was hospitalized on (MONTH) 27, (YEAR) through (MONTH) 29, (YEAR) and (MONTH) 19, (YEAR) through (MONTH) 12, (YEAR). A total of nine (9) MDS assessments were completed for Resident #1. The MDS with a target date of (MONTH) 19, (YEAR) (return from hospitalization s) was the only MDS that lacked the active [DIAGNOSES REDACTED]. Additionally, eight (8) MDS assessments identified the resident as requiring an assist of two (2) persons with bed mobility (Item GO 110A). Only the MDS assessment completed (MONTH) 13, (YEAR), was marked as the resident requiring the assist on one (1) person for bed mobility. A face-to-face interview was conducted with Employee #1 on (MONTH) 23, (YEAR) at 1:30 PM. Employee #1, Rehabilitation Therapist, assessed the resident as unable to initiate any spontaneous movement. He/she demonstrated no spontaneous gross movements. His/her upper and lower extremities were contracted. He/she recommend two (2) staff to move the resident, either for bed mobility or transfers. Employee #2 acknowledged the inaccuracy of the MDS.",2020-09-01
99,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-10-23,657,D,1,0,FXOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and staff interviews and record review, it was determined that facility staff failed to accurately develop a comprehensive care plan, identifying that the residents required the assistance of two (2) persons for bed mobility. Residents #1and #2 The findings include: Resident #1 was admitted to the facility on (MONTH) 11, (YEAR). According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 19, (YEAR), Resident #1 was assessed as requiring extensive assistance with two person assist for bed mobility (Item GO110A on the MDS) in Section G (Functional Status) Resident #2 was admitted on (MONTH) 9, (YEAR). According to the MDS assessment with a target date of (MONTH) 16, (YEAR) Resident #2 was assessed as requiring extensive assistance with two person assist for bed mobility in Section G (Item GO110A on the MDS). Resident #3 was admitted on (MONTH) 30, 2010. According to the MDS assessment with a target date of (MONTH) 21, (YEAR), Resident #3 was assessed as requiring extensive assistance with two person assist for bed mobility in Section G (Item GO110A on the MDS). Face-to-face interviews were conducted with Residents #2 and #3 on (MONTH) 23, (YEAR) between 12:00 PM and 2:00 PM. Both residents acknowledged that they consistently receive the assist of one (1) person for bed mobility. A review of the care plans for Residents #1 and #2 revealed the following: Resident #1 According to the resident's admission care plan: Problem: Resident #1 has an ADL Self Care performance Deficit r/t (related to) MS, multiple wounds, [MEDICAL CONDITION]. Intervention: Bed mobility: reposition and turn resident q (every) 2 hrs while in bed for pressure relief. Problem: Resident #1 has limited physical mobility r/t MS, contractures of all extremities, limited mobility, [MEDICAL CONDITION]. Intervention: Mobility: resident requires staff participation for mobility/uses wheelchair for mobility. Monitors/document/report to MD PRN s/sx (signs/symptoms) of immobility, worsening of contractures, thrombus formation, worsening of skin-breakdown, fall related injury. Provide gentle range of motion as tolerated with daily care. PT, OT referrals as ordered. Resident #2 According to the resident's admission care plan: Problem: Resident #2 has an ADL self-care performance deficit r/t limited mobility, wound to lower extremities. Intervention: Bed Mobility: Remind resident to turn and reposition while in bed q 2 hours for pressure relief. Resident #3 Problem: Resident #3 requires total assistance for transfers related to: unsteady gait physical limitations, lack of strength. Interventions: Transfer: Requires two staff assistance when transferring. There was no care plan problem for Resident #3 that required the assistance of two persons for bed mobility. Facility staff failed to include the intervention to use two (2) person assist for bed mobility for Residents #1, #2 and #3. Employee #2 acknowledged the above finding.",2020-09-01
100,SERENITY REHABILITATION AND HEALTH CENTER LLC,95015,1380 SOUTHERN AVE SE,WASHINGTON,DC,20032,2018-10-23,689,G,1,0,FXOI11,"> Based on staff and resident interviews and record review for three (3) of three (3) residents, it was determined that facility staff failed to utilize two (2) persons to assist with bed mobility. Subsequently, Resident #1 fell out of bed, sustained a laceration to the forehead and was subsequently sent to the hospital by 911. The findings include: Resident #1 was admitted to the facility on (MONTH) 11, (YEAR). According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 19, (YEAR), Resident #1 scored 9/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). Resident #1 was assessed as requiring extensive assistance with two person assist for bed mobility (Item GO110A on the MDS) in Section G (Functional Status) Resident #2 was admitted on (MONTH) 9, (YEAR). According to the MDS with a target date of (MONTH) 16, (YEAR) Resident #2 scored 15/15 for the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14 a score of 13-15 suggests the resident is cognitively intact. Resident #2 was assessed as requiring extensive assistance with two person assist for bed mobility in Section G (Item GO110A on the MDS). Resident #3 was admitted on (MONTH) 30, 2010. According to the MDS with a target date of (MONTH) 21, (YEAR), Resident #2 scored 10/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14 a score of 8-12 suggests the resident has moderately impaired cognitive skills for daily decision making. Resident #3 was assessed as requiring extensive assistance with two person assist for bed mobility in Section G (Item GO110A on the MDS). Face-to-face interviews were conducted with Residents #2 and #3 on (MONTH) 23, (YEAR) between 12:00 PM and 2:00 PM. Both residents acknowledged that they consistently receive the assistance of one (1) person for bed mobility. Residents #1, #2 and #3 utilized an air mattress. A face-to-face interview was conducted with Employee #6 on (MONTH) 23, (YEAR) at 10:00 PM. Employee #6 stated, Right after that happened, when Resident #1 fell , I gave an in-service to everyone. I stressed that every resident on an air mattress must have two persons to do care, to help with the turning of the resident. Face-to-face interviews were conducted with Employees #4 and #5 on (MONTH) 23, (YEAR) between 9:00 AM and 12:00 PM. Employee #4 cared for Resident #2 and Employee #5 cared for Resident #3 on (MONTH) 23, (YEAR). Both employees acknowledged that they assisted Resident #2 and Resident #3 with ADL care (including bed mobility) by themselves, without a second person to assist on (MONTH) 23, (YEAR). Employee #2 acknowledged that the above findings.",2020-09-01