cms_DC
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2,583 rows sorted by facility_id
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| Link | rowid | facility_name | facility_id ▼ | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1451 | 1451 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 160 | D | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 51 sampled records related to residents' personal funds accounts, it was determined that facility staff failed to convey funds within 30 days of the death of two (2) residents. Residents' #T1 and #T2. The findings include: 1. Facility staff failed to convey funds within 30 days of the death of Resident #T1. A personal funds account review was conducted on [DATE] at approximately 3:00 PM with Employee #29 and the following was identified: The Resident's Fund Management Service Status Change Form revealed that the resident expired on [DATE]. The Resident's Fund Management Service: Closed Account Summary form from: [DATE] to [DATE] revealed that the account was closed on [DATE]. The check payable to the (relative ' s name) in the amount of $37.00 was dated February 21, 2014. A face-to-face interview was conducted on [DATE] at approximately 3:00 PM with Employee #29. A query was made regarding the delay in closing and conveying the resident ' s funds to the relative. Employee #29 stated that the delay was due to the fact that the (deceased ) resident ' s (relative) could not be found. We (facility) had to go through another family member. Facility staff failed to convey funds within 30 days of the resident's death. 2. Facility staff failed to convey funds within 30 days of the death of Resident #T2. A review of the Resident's Fund Management Service Status Change Form revealed that the resident expired on [DATE]. The Resident's Fund Management Service: Closed Account Summary form from: [DATE] to [DATE] revealed that the account was closed on [DATE]. However, the check payable to the (relative ' s name) in the amount of $70.03 was dated February 18, 2014. A face-to-face interview was conducted on [DATE] at approximately 3:00 PM with Employee #29. A query was made regarding the delay in closing and conveying the resident ' s funds to the relative. Employee #29 stated that the delay was due t… | 2017-02-01 |
| 1452 | 1452 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 164 | D | 0 | 1 | 0SN511 | Based on observations and interview for one (1) of 51 sampled residents, it was determined that facility staff failed to provide privacy during toileting of a resident as evidenced by an observation of one (1) resident who was exposed from his/her head to his/her groin area while using the urinal in his/her room with the door open and in plain view of passersby for Resident #1. The findings include: Facility staff failed to provide privacy to Resident #1 who was observed exposed from (his/her) head to (his/her) groin area while using the urinal in (his/her) room with the door open and in plain view of staff, other residents and visitors who passed by the room. On April 17, 2014 at approximately 10:18 AM, Resident #1 was observed exposed from (his/her) head to (his/her) groin area. He/she had a clear colored urinal in (his/her) left hand at his/her groin area. The door to the room was open. The surveyor was standing in the hallway when the observation was made. Employee #39 was approximately four feet from the resident ' s room door, acknowledged the finding and closed the door to the room. There was no evidence that facility staff provided privacy to Resident #1 when (he/she) was observed using a urinal in (his/her) room with the door open and in plain view of staff, other residents and visitors. The observation was made on April 17, 2014. | 2017-02-01 |
| 1453 | 1453 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 166 | D | 0 | 1 | 0SN511 | Based on record review and staff interview for one (1) of 51 sampled residents, it was determined that facility staff failed to resolve a grievance for Resident #174 ' s allegation of physical abuse. The findings include: The Resident/Family Communication Tool Concern form initiated on February 24, 2014 at 11:30 PM by the facility staff on behalf of Resident #174 revealed: Resident Name and Room Number: (Resident ' s name and room number); Detailed Information: February 27, 2014- 10:40 PM- (Registered Nurse) was notified by (evening charge nurse named) that the resident reported that (he/she) was smacked on (his/her) face by (his/her) CNA (Certified Nursing Assistant) 15 minutes ago. . It was observed that resident ' s right side of eye sclera was reddish with minimal watery drainage. No swelling noted to external upper/lower eyelids. No visible skin discoloration nor any swelling noted to (his/her) face, mouth and nose. (He/she) denied any pain . (Named physician) was notified of resident ' s right eye redness, (neurological) checks ordered. Medical team to follow up in AM (morning). (Resident ' s responsible party named) was also notified by phone. The back of the Resident/Family Communication Tool Concern form revealed, Describe action taken to address concern: Copy provided to Clinical Manager (unit named) to follow-up. Signed :(evening supervisor's signature ); Concern Resolved- space left blank ; Dated Resolved- Blank; Reviewed by (space for Administrator ' s signature): was left blank; Date; was left blank. According to the Facility ' s Policy and Procedure, Family/Resident Communication Tool revised October 2010 stipulates: (#) 9. The Department Director/Manager or designee receiving the concern will contact the writer of the Family/Resident Communication Tool by telephone, within five (5) business days with a response and/or resolution. 10. It is the responsibility of the Department Director/Manager or designee to document on the Family/Resident Communication Tool the date, time and spoken to in regards … | 2017-02-01 |
| 1454 | 1454 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 176 | D | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interview for two (2) of 51 sampled residents, it was determined that facility staff failed to ensure that the residents medications were properly stored and the residents were monitored for self administration of medications. Residents ' #136 and #300. The findings include: Review of the facility ' s policy Self Administration of Medication, Revised 01/11 stipulates; Policy: Residents who desire to exercise their right to self-administer their medications are assessed by the interdisciplinary care plan team to be appropriate; An initial assessment is conducted followed by a quarterly reassessment, with a change in condition and more frequently as indicated. Procedure: The attending physician must write an order that the medications may be kept in the resident ' s room, the licensed nurses must monitor the use of medications and maintain documentation in the medical record, the licensed nurses must instruct the resident of proper use of medications including what the medication is for, how it is used, (and) how often the medication is used. This information will be documented in the resident ' s medical record. 1. Facility staff failed to ensure medications for Resident #136 could be kept in his/her room and that he/she could self administer his/her own eye drops and shampoo. During a resident interview conducted on April 15, 2014 at approximately 10:15 AM, it was observed that the resident had eye drops and baby shampoo on the over bed table. A query was made to the resident regarding the medication on the table and if (he/she) is allowed to administer (his/her) own eye drops and shampoo. The resident stated yes, this is my medication, I have to give myself eye drops for eye irritation, I give myself my own eye drops, and I use the shampoo too. The Interim Order Form dated and signed March 24, 2014, it directed, .(1) warm compression x (times) 5 minutes; (2) clean eye lash area with 3 … | 2017-02-01 |
| 1455 | 1455 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 221 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview for eight (8) of 51 sampled residents, it was determined that facility staff failed to ensure residents were free from physical restraints as evidenced by: eight (8) residents who were observed seated in mobility aids merry walkers and were unable to self release and exit at will. Residents' #26, 43, 95, 102, 106, 118, 183 and 177. The findings include: According to the Code of Federal Regulations 483.13 (a) Restraints- Definition of Terms stipulates; An enclosed framed wheeled walker, with or without a posterior seat, would not meet the definition of a restraint if the resident could easily open the front gate and exit the device. If the resident cannot open the front gate (due to cognitive or physical limitations that prevent him or her from exiting the device or because the device has been altered to prevent the resident from exiting the device), the enclosed framed wheeled walker would meet the definition of a restraint since the device would restrict the resident ' s freedom of movement. The Facility's Policy and Procedure No.TX- .11 - Restraints Physical: effective 04/11 and revised 10/11 stipulated the following: If the IDT (Interdisciplinary Team) determines a physical restraint is needed for a resident an assessment must be completed prior to placement of the resident, quarterly, and with any significant change. Any resident requiring the use of a restraint, as determined by the IDT, must have a restraint reduction assessment completed quarterly and /or with a significant change . Procedure: Steps for Assessment 1. Consult with the IDT to determine the resident ' s cognitive and physical limitations. 2. Review the resident ' s medical record. 3. Review the definition of restraint: focus on the effect the device will have on the resident, not the type of device. 4. If the device meets the definition of a restraint complete the following as applicable. a. Pre-restraining Assessme… | 2017-02-01 |
| 1456 | 1456 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 226 | D | 0 | 1 | 0SN511 | Based on resident interview and record review for two (2) of 51 sampled residents, it was determined that facility staff failed to report allegations of verbal abuse and misappropriation of property for one (1) resident and an allegation of mistreatment for one (1) resident. Residents #6 and 28. The findings include: Facility staff failed to report an allegation of staff to resident verbal abuse and possible misappropriation of property (items not specified). During a resident interview conducted on April 17, 2014 at 2:00 pm with Resident #6, he/she stated I had two (2) legitimate complaints about two (2) CNA ' s (Certified Nurse ' s Assistant). A. The first complaint involved a CNA that had been accused of stealing by other people. I saw (him/her) go into my cabinet when (he/she) thought I was asleep. That employee was suspended and brought back and I agreed to let (him/her) work with me again. The resident did not specify the date of alleged occurrence. A review of the facility ' s Disciplinary Action Form revealed that Employee #23 was suspended on December 4, 2013 and returned to duty, allegations were not confirmed. A face-to-face interview was conducted on April 18, 2014 at 11:00 AM with Employees #1, 2 and 12. A query was made regarding the above incident. Employee #1 stated the incident was investigated and not substantiated. B. Resident #6 alleged that a CNA would yell and be moody and snappy at times. Talking with him/her (the CNA) was not effective. The resident did not specify a date of occurrence. A face-to-face interview was conducted on April 18, 2014 at 11:00 AM with Employees #1, 2 and 12. A query was made regarding if the State Agency was notified regarding Resident #6 ' s allegations. Employee #1 stated that the facility ' s form, Resident/Family Communication Tool was completed, however; he/she had no evidence to support notification to the State Agency. Facility staff failed to report an allegation of verbal abuse and misappropriation of property for Resident #6. 2. Facility staff failed to r… | 2017-02-01 |
| 1457 | 1457 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 241 | E | 0 | 1 | 0SN511 | Based on observations and staff interviews for three (3) of 51 sampled residents, it was determined that facility staff failed to promote dignity as evidenced by posting of signage of resident ' s personal plan of care for (2) residents and one (1) resident whose name was written on the front of his/her jacket. Residents #34, #62 and #115. The findings include: 1. Facility staff failed to promote dignity for Resident #34 as evidenced by the observation of signage of resident ' s confidential clinical and personal information that could be viewed by the public. During a resident observation conducted on April 15, 2014 at approximately 11:40 AM and April 22, 2014 at approximately 1:00 PM; observed signage posted on wall behind the head of Resident #34 ' s bed. The signage revealed; No B/P (blood pressure) or venipuncture on right arm. Aspiration precautions: Diet: Pure; Position meal tray on right side. A face-to-face interview was conducted on April 22, 2014 at approximately 1:00PM with Employees #5 and #7. In response to a query regarding the signage observed posted behind Resident #34 ' s bed; both replied that the signage is not to be visibly posted. The observation was made on April 22, 2014. Facility staff failed to promote dignity for Resident #34 as evidenced by the observation of signage of resident ' s confidential clinical and personal information that could be viewed by the public. 2. During tour of Resident #62 ' s room on April 14, 2014 and April 22, 2014 between the hours of 9:00 AM and 4:00 PM, observed signage posted on wall behind the resident ' s head of bed. The signage revealed; Resident name, Full Code, Bathing: Total Care; Dressing: Total Care; Toilet Transfers-Dependent; Ambulation- Assistive device/at risk for falls/WC (wheelchair); Diet: Diabetic Regular NCS (No Concentrated Sweets); Oral Care: Partials/Dentures; Toileting: Adult briefs (size) M (medium); Activities: Participate Ad-lib (as often as liked); Vigelon monitor on chair . Second signage revealed; Attention Staff: Swallowing Prec… | 2017-02-01 |
| 1458 | 1458 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 253 | E | 0 | 1 | 0SN511 | Based on observations made during an environmental tour of the facility on April 18, 2014 at approximately 11:00 AM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by seven (7) of seven (7) torn window curtains in two (2) of 27 resident's rooms, loose wallpaper in three (3) of five (5) resident's units, broken window blinds slats in two (2) of 27 resident's rooms and marred walls in four (4) of 27 resident's rooms. The findings include: 1. Five (5) of five (5) sets of window curtains in room #351 were torn in several areas and one (1) of one (1) set of window curtains in room #349 was also torn, two (2) of 27 resident's rooms. 2. The wallpaper was hanging loose, unglued from the wall in three (3) of five (5) resident's units. 3. One (1) of five (5) window blinds had a broken slat in room #254 and two (2) of two (2) window blinds in room #128 had broken slats; two (2) of 27 resident's rooms surveyed. 4. The walls were marred in four (4) of 27 resident's rooms (#254, #154, #135, #129). These observations were made in the presence of Employee #9 who acknowledged the findings. | 2017-02-01 |
| 1459 | 1459 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 272 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on record review and staff interview for five (5) of 51 sampled residents, it was determined that the facility staff failed to accurately code the Minimum Data set (MDS) for one (1) resident's total care, urinary continent and [DIAGNOSES REDACTED]. edentulous on the significant change MDS, one (1) resident for [DIAGNOSES REDACTED]. Residents #1, #34, #62 ,#116, #252 and #291 The findings include: 1a. Facility staff failed to accurately code Resident #1's Minimum Data Sets (MDS) for total care, urinary continent and [MEDICAL CONDITION]. A review of the clinical record for Resident #1 revealed facility staff failed to accurately code Section G, Functional Status - G0110 Activity of Daily Living Assistance of the quarterly MDS dated [DATE] and annual MDS dated [DATE]. The check box allotted next to Section G0110 - Activity of Daily Living Assistance was coded as 4 indicating that the resident was total dependence (full staff performance every time during entire 7-day period). On April 17, 2014 at approximately 10:18 AM, Resident #1 was observed exposed from his/her head to his/her groin area with a clear colored urinal in his/her left hand. He/she was observed independently using (his/her) urinal. The observation of Resident #1 independently using the urinal on April 17, 2014 at approximately 10:18 AM provided evidence that facility staff miscoded MDS Section G0110 - Activity of Daily Living Assistance. A face-to-face interview was conducted with Employee # 27 on April 17, 2014 at approximately 10:22 AM. He/she reviewed the clinical record and acknowledged the findings. The record was reviewed April 17, 2014. 1b. A review of the clinical record for Resident #1 revealed facility staff failed to accurately code Section G, Functional Status - H0300 Urinary Continence of the quarterly MDS dated [DATE] and annual MDS dated [DATE]. The check box allotted next to Section H0300A - Urinary Continence was coded as 3 indicating that the resident w… | 2017-02-01 |
| 1460 | 1460 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 279 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 51 sampled residents, it was determined that facility staff failed to develop care plans with goals and approaches for the management of a Nephrostomy tube for one (1) resident, one (1) resident receiving hospice services and for the use of compression stockings for one (1) resident with [MEDICAL CONDITION]. Residents # 207, #211 and #252 The findings include 1. Facility staff failed to develop a care plan with goals and approaches to address resident#207 ' s use of a Nephrostomy tube. This was a closed record review. A review of the physician history and physical signed and dated December 14, 2013 revealed, . Nephrostomy tube placement secondary to acute [MEDICAL CONDITION]. A review of physician's order [REDACTED]. Change dressing to Nephrostomy tube every three days and as needed. Flush Nephrostomy tube every 8hrs (hours) with 30ml (milliliters) water. Measure output every shift. A review of the care plan section lacked evidence that a care plan with goals and approaches were developed to address Resident #207 ' s Nephrostomy tube management. A face-to-face interview was conducted on April 15, 2014 at approximately 11:20 AM with Employee #7. He/she acknowledged the findings after reviewing the record. The record was reviewed April 15, 2014. 2. Facility staff failed to develop a jointly coordinated care plan with goals and approaches between the facility and the hospice services for Resident #211. A review of the Physician order [REDACTED]. According to the Interdisciplinary Progress Note dated February 24, 2014, no time indicated, [AGE] year old woman with [MEDICAL CONDITIONS] admitted to (facility name) 2/21/14 (February 21, 2014) DNR/DNI (Do Not Resuscitate/Do Not Intubate) in Hospice. Review of the Progress Notes by Resident progress notes identified that hospice care had been conducted February 22, 2014 through March 12, 2014. Review of the resident ' s care plans lacked evide… | 2017-02-01 |
| 1461 | 1461 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 280 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview for three(3) of 51 sampled residents, it was determined that facility staff failed to review and revise a care plan with goals and approaches to reflect the resident ' s current status for one (1) resident with a change in delivery of ADL (Activities of Daily Living) care; one (1) who refused care, one (1) resident abnormal INR (international Normalized Ratio) levels. Residents #6, #122 and #154 The findings Include: 1. Facility staff failed to review and revise a care plan for Resident #6 who had a change in delivery of ADL care. A resident interview was conducted on April 17, 2014 at approximately 2:00 PM with Resident #6. The resident stated that on all three (3) shifts that his/her care has been expanded to include two (2) CNA ' s (Certified Nursing Assistants), and that he/she could understand a second person during the night shift for turning and repositioning because of the wedge pillow that is put in place, but not on all three (3) shifts. Resident #6 further indicated that there is also a timer placed in his/her room to let the CNA ' s know when 45 minutes are up, that is the time limit to provide care to me. A face-to-face interview was conducted on April 18, 2014 with Employees #1, #2, and #12 at approximately 2:00 PM. A query was made regarding the above statement voiced by the resident. Employee #2 stated there are two (2) persons per shift to perform direct care, if water needed or if trash is to removed, there is only a need for one (1) person. The 45 minute timer is still in use. A review of the resident care plan lacked evidence of revision to include the two (2) CNA ' s that are required for direct care during all three (3) shifts and a time to identify 45 minutes of time allowed to provide care by the CNA. A face-to-face interview was conducted with Employee #6 on April 21, 2014 at approximately 1:00 PM. After review of the care plan he/she acknowledged the findings and stated that the p… | 2017-02-01 |
| 1462 | 1462 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 281 | D | 0 | 1 | 0SN511 | Based on observations and staff interview for two (2) of 51 sampled resident, it was determined that facility staff failed to ensure proper techniques were followed according to accepted standards of clinical practice prior to administration of medications. Residents #78 and #182. The findings include: Facility staff failed to ensure proper techniques were followed according to accepted standards of clinical practice prior to administer medications via the gastrostomy tube for Residents #78 and #182. Employee #34 was observed on April 14, 2014 during two (2) medication pass at approximately 12:30 PM and 1:10 PM. The employee was observed preparing Resident #78 and #182 ' s medications. Prior to administering the medications via gastrostomy tube, he/she informed the residents the indications for each medication. After checking for residual, Employee #34 proceeded to administer each medication separately through a 60 ml (millimeter) syringe attached to the gastrostomy tube and allowed each to infuse by gravity. He/she did not check for correct placement of the gastrostomy tube prior to the administration of the medications. The facility ' s policy entitled; Medication Administration, Policy No: TC- .12, page 5 of 6 stipulates: Prior to infusion of a feeding and/or before administering medications via a feeding tube, the feeding tube must be checked for placement each time. To accomplish this task do the following: Remove the plug from the end of the tube, Attach a 50-60 ml. syringe to the end of the tube, Place a stethoscope over the abdomen approximately 3cm below the sternum. Unclamp tube and inject 10 ml of air into the stomach: listen for a gurgling sound- gurgling equals probable proper placement of tube, As a second check, draw back on the syringe and aspirate stomach contents: . According to The Lippincott Manual of Nursing Practice , Seventh edition, page 664 stipulates; Procedure- Nursing Action-Preparatory Phase- #7. Use the catheter-tipped syringe, inject 20 cc-30cc of air while listening with a stethosc… | 2017-02-01 |
| 1463 | 1463 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 309 | E | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview for ten (10) of 51 sampled residents, it was determined that facility staff failed to ensure that each resident received necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by a failure to: administer medications in accordance with physician's orders for three (3) residents; assess oxygen saturation levels for one (1) resident as prescribed; consistently conduct monitoring and assessments for one (1) resident with a respiratory disorder; provide end of life services and implement end of life policies for three (3) residents identified as receiving palliative care; assess oxygen saturation levels as prescribed for one (1) resident; obtain physician's orders for one (1) resident who received hospice services and assess the level of pain for one (1) resident prescribed more than one (1) [MEDICATION NAME] for pain. Residents #78, #95, #98, #106, #153, #182, #211, 213, #291, #305. The findings include: The facility ' s policy entitled; Medication Administration, Policy No: TC- .12, page 5 of 6 stipulates: Prior to infusion of a feeding and/or before administering medications via a feeding tube, the feeding tube must be checked for placement each time. To accomplish this task do the following: Remove the plug from the end of the tube, Attach a 50-60 ml. syringe to the end of the tube, Place a stethoscope over the abdomen approximately 3cm below the sternum. Unclamp tube and inject 10 ml of air into the stomach: listen for a gurgling sound- gurgling equals probable proper placement of tube, As a second check, draw back on the syringe and aspirate stomach contents: . The American Academy of Hospice and Palliative Medicine (AAHPM) www.aahpm.org Clinical Practice Guidelines for Quality Palliative Care Statement: The goal of palliative care is to preven… | 2017-02-01 |
| 1464 | 1464 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 323 | E | 0 | 1 | 0SN511 | Based on observations made during an environmental tour of the facility on April 18, 2014 at approximately 11:00 AM, it was determined that facility staff failed to maintain the facility free of accident hazards as evidenced by: four (4) of four (4) power strips and two (2) of two (2) extension cords that were observed on the floor in three (3) of 27 resident's rooms, unsercured oxygen tanks in two (2) of five (5) storage rooms and in one (1) of 27 resident's rooms and one (1) of one (1) mirror that was stored on top of a dresser unsecured in one (1) of 27 resident's rooms. The findings include: 1. Three (3) of three (3) power strips were in use and stored on the floor of room # 356A, one (1) of one (1) power strip was in use and stored on the floor of room #323, two (2) extension cords were in use and on the floor of room #323, and a three-outlet, electrical connector was in use in room #305, three (3) of 27 resident's rooms. 2. Oxygen tanks were observed unsecured on numerous occasions including: One (1) of eight (8) E-cylinder type tank in the Oxygen storage room on Unit 3A (#A345A) in one (1) of five (5) Oxygen storage rooms and two (2) of 14 E-cylinder type tanks in the Oxygen storage room on Unit 1, two (2) of five (5) Oxygen storage rooms. One (1) of one (1) E-cylinder type tank in resident room #129, one (1) of 27 resident's rooms. 3. One (1) of one (1) mirror was observed on top of a dresser, loose and unmounted in room #135, one (1) of 27 resident's rooms. These observations were made in the presence of Employee #9 who acknowledged the findings. | 2017-02-01 |
| 1465 | 1465 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 332 | D | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview for two (2) medication pass observations conducted, it was determined that facility staff failed to instill eye drops according to physician orders [REDACTED]. Residents' #213 and #217. The findings include: 1.Facility staff failed to ensure Resident #213 was administered a nasal spray in accordance to the physician's orders [REDACTED]. A medication observation was conducted on April 15, 2014 at approximately 10:00 AM. During the observation Employee #16 administered two (2) sprays of Deep Sea 0.65% Spray in each nostril of the resident. A review of the April 2014physician's orders [REDACTED]. Facility staff failed to ensure that a nasal spray was administered to resident in accordance with the physician's orders [REDACTED]. A face-to-face interview was conducted with Employee #16 on April 15, 2014 at approximately 10:15 AM. He/she acknowledged that the resident was administered two (2) sprays in each nostril at the time of the administration. The observation occurred on April 15, 2014. 2. Facility staff failed to ensure Resident #217 was administered the correct amount of eye drops in accordance with physician orders. According to the physician's orders [REDACTED]. According to the Medication Administration Record (MAR) for April 2014, it directed Dorzolamide - Timolo 2% (percent)-0.5% original order date March 18, 2014 .Drops; [MEDICATION NAME] PLUS: Instill 1 drop to right eye twice daily, for [MEDICAL CONDITION] . During a medication pass observation with Employee #40 on April 14, 2014, at approximately 10:49 AM the following was observed: After Employee #40 followed necessary measures to ensure sanitization of hands, identification of the resident and ensuring the right medication by reading the label on the medication bottle and the physician's orders [REDACTED]. Employee #40 used his/her left hand to open the lower lid and the right had to hold the eye drops, the resident assiste… | 2017-02-01 |
| 1466 | 1466 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 371 | D | 0 | 1 | 0SN511 | A. Based on observations made on April 17, 2014 at approximately 9:00 AM, it was determined that the facility failed to store, prepare, distribute and serve food under sanitary conditions as evidenced by expired foods in one (1) of three (3) refrigerators, one (1) of one (1) soiled flat top grill and two (2) of two (2) soiled convection ovens and two (2) of three (3) soiled air curtains fron one (1) of one (1) dishwashing machine. The findings include: 1. A one-third pan of guacamole stored in refrigerator #3 was expired as of April 12, 2014 and a partially filled salad bar container with shredded yellow cheese stored in refrigerator #3 was expired as of April 13, 2014. 2. One (1) of one (1) flat top grill and two (2) of two (2) convection ovens were soiled. 3. Two (2) of three (3) air curtains from the dishwashing machine were soiled. These observations were made in the presence of Employee #8 who acknowledged the findings. B. Based on observation and staff interview, for one (1) of 51 sampled residents, it was determined that facility staff failed to prepare residents food in a sanitary manner as evidenced by the following: The findings include: During a dining observation conducted on April 18, 2014 at approximately 1:00 PM. Employee #33 was observed touching a resident ' s food with his/her bare hands. A face-to-face interview was conducted with Employee #4 on April 22, 2014 at approximately 2:00 PM. After review of the above, he/she acknowledged the findings and stated that we have gloves on the unit that is not acceptable. | 2017-02-01 |
| 1467 | 1467 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 431 | D | 0 | 1 | 0SN511 | Based on observations made on one(1) of four nursing units it was determined that the facility failed to ensure that one (1) of one (1) of vial of Influenza Virus Vaccine was stored beyond the expiration date. The findings include: At approximately 10:30 AM, on April 15, 2014, in the medication storage refrigerator, one (1) vial of Influenza Virus Vaccine was observed with an open date of 2/2/14. Expiration date on the vial was March, 2014. The observation was made in the presence of Employee # 5. He/she acknowledged the findings. | 2017-02-01 |
| 1468 | 1468 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 441 | D | 0 | 1 | 0SN511 | Based on observations, staff interview and record review for three (3) of 51 sampled residents, it was determined that the facility failed to follow infection control practices to prevent potential cross contamination and spread of infection as evidenced by: failure to clean the over bed table after removing a urine filled catherization tray for one (1) resident, and failure to wash/sanitize hands prior to administration of medications for two (2) residents. Residents' #1, #78 , #182. The findings include: 1. Facility staff failed to clean Resident #1's over-bed table after removing a urine filled catherization tray. On April 21, 2014 at approximately 12:30 PM Employee #38 was observed performing an in and out catherization. After measuring the urine, he/she picked up the catherization tray from the over bed table and emptied the urine into the commode. Employee #38 proceeded to dispose of the tray in the trash can. After washing his/her hands, he/she readjusted the resident, washed his/her hands and left the resident's room. After the nurse returned to the medication cart, he/she was asked had she finished caring for the resident,. he/she replied, Yes. At that time she was told that she failed to clean the overbed table. He/she acknowledged theaforementioned finding in the presence of Employee #3. The observation was conducted on April 21, 2014. Facility staff failed to clean Resident #1's over bed table after removing a urine filled catherization tray. 2. Facility failed to follow accepted standards of hand hygienepractices during medication administration for Resident #78. During a medication pass observation on April 14, 2014 at approximately 12:30 PM. Prior to administering Resident #78's medication. Employee #34 washed his/her hands and donned gloves. He/she repositioned the resident's wheelchair and locked its brakes. Using the same gloved hands, he/she proceeded to administer the medication through Resident #78's gastrostomy tube. Facility failed to follow infection control practices to prevent potential … | 2017-02-01 |
| 1469 | 1469 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 456 | D | 0 | 1 | 0SN511 | Based on observations made on April 17, 2014 at approximately 9:00 AM, it was determined that the facility failed to maintain all essential mechanical, electrical, and patient care equipment in safe operating condition as evidenced by two (2) of five (5) Reach-in refrigerators and one (1) of two (2) freezers that have been out of order for more than a year, five (5) of five (5) type E fire extinguishers and two (2) of two (2) type K fire extinguishers that have not been inspected monthly. The findings include: 1. Two (2) of five (5) Reach-in refrigerators located in the kitchen have been out of order for about a year. 2. One (1) of two (2) freezers was inoperable. 3. Fire extinguishers located in the kitchen are not inspected monthly as required. These observations were made in the presence of Employee #8 who acknowledged the findings. | 2017-02-01 |
| 1470 | 1470 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 463 | E | 0 | 1 | 0SN511 | Based on observations made during an environmental tour of the facility on April 18, 2014 at approximately 11:00 AM, it was determined that facility staff failed to maintain call bells in good working condition as evidenced by call bells that fail to function as intended in three (3) of 27 resident's rooms, frayed call bell cords in two (2) of 27 resident's rooms and a call bell that was secured with transparent tape in one (1) of 27 resident's rooms. The findings include: 1. Call bells in rooms #249B, #237A and #116 did not consistently initiate an alarm when tested , in three (3) of 27 resident's rooms. 2. Call bell cords were torn and frayed in two (2) of 27 resident's rooms #154 and #114 and the call bell in room #128 was secured with transparent tape in one (1) of 27 resident's rooms (#128). These observations were made in the presence of Employee #9 who acknowledged the findings. | 2017-02-01 |
| 1471 | 1471 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 492 | E | 0 | 1 | 0SN511 | A. Based on record review and staff interview for four (4) of 7 sampled residents reviewed for transfer/discharge rights; it was determined that facility staff failed to provide transfer/discharge and appeal rights notices in accordance with state law. D.C. Law 6-108. Residents 37, 59, 237 and 299. The findings included: Pursuant to D.C. Code ?44-1001.01.1; Law 6-108 .Whenever a resident is to be discharged , transferred or relocated, a facility representative shall give that resident and his or her representative both oral and written notice of the reasons for, procedures for contesting and proposed effective date of the discharge, transfer or relocation . During a review of clinical records on April 21, 2014 at approximately 5:00 PM, the following residents were transferred out of the facility and there was a lack of documented evidence that transfer/discharge and/or appeal rights notices were provided to the residents and/or their representative. Resident #237- Transferred to hospital on April 2, 2014. Had not returned to facility. Resident #59- Transferred to hospital on March 28, 2014; returned to facility on April 7, 2014 Resident #37- Transferred to hospital on March 4, 2014; returned to facility. Resident #299- Transferred to hospital on April 3, 2014; had not returned. Facility staff failed to provide transfer/discharge notices and appeal rights as required by state law. A face-to-face interview was conducted with Employee#12 on April 21 2014 at approximately 5:00 PM. He/she stated they have been having problems with the submission of the forms. When they are not done electronically, it is done manually. He/she further stated that one of the social worker positions was vacant and the other social workers were covering. The clinical record was reviewed on April 21, 2014. B. Based on record review and staff interview during a review of staffing (direct care per resident day hours), it was determined that facility staff failed to meet minimum nurse staffing requirements in accordance with Title 22 DCMR Sect… | 2017-02-01 |
| 1472 | 1472 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-04-22 | 514 | D | 0 | 1 | 0SN511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 51 sampled residents, it was determined that facility staff failed to initiate transfer orders for one (1) resident transferred to the emergency room , record the correct date on a STAT (administer immediately) potassium chloride order for one (1) resident, document a physician's order [REDACTED]. Residents #23, #207, #211 The findings include: 1. Facility staff failed to initiate 6-108 for Resident #23 ' s transfer to the emergency room (ER). Resident #23 was transferred to acute hospital ER for evaluation. No 6-108 was generated. A face to face interview was conducted with Employee #12 on April 21, 2014 at approximately 5:00 PM. He/she acknowledge the aforementioned findings. 2. Facility staff failed to document the correct date for Resident #207 ' s potassium chloride (KCl) order. This was a closed record review. A review of a physician order [REDACTED]. A review of the Medication Administration Record [REDACTED]. The Potassium chloride was then continued to be administered on December 23, 2013 at 9AM to be given daily per physician order. A review of the Interim order form revealed that the KCL order signed and dated December 24, 2013 was documented on December 20, 2013 at 2:25PM as evidence by the verification date December 20, 2013 at 6:00PM written across the page of the medication order. Facility staff was queried concerning the difference in the documented physician date compared to the date of medication administration. Employee #2 stated that the physician wrote the wrong date when he/she was prescribing Resident #207 ' s order. A face-to-face interview was conducted on April 22, 2014 at approximately 3:05PM with Employee #2. He /she acknowledge the findings. Facility staff failed to document the correct date for Resident #207 ' s potassium chloride (KCL) order. This was a closed record review. The record was reviewed April 22, 2014. 3a. Facility staff failed to write hosp… | 2017-02-01 |
| 1473 | 1473 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2014-08-14 | 282 | D | 1 | 0 | BIX611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record review, it was determined that facility staff failed to follow interventions initiated for Resident #1 to prevent lab draws from the left arm and hand. The findings include: Resident #1 was admitted to the facility on [DATE]. According to the Minimum Data Set assessment, with an assessment reference date of June 26, 2014, Resident #1 was assessed with [REDACTED]. Resident #1 was assessed as requiring extensive assistance for transfers, walking, and bathing and totally independent for bed mobility, dressing, eating, toilet use, and personal hygiene in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated July 4, 2014 at 9:40 AM: Around 6:45 AM, CNA assigned to resident reported that he/she was in the middle of changing the resident when he/she heard a knock on the door and saw the Lab tech enter the room without waiting for a response. CNA said he/she asked the lab tech to wait but he/she proceeded to draw the blood. Lab tech drew the blood from the back of the left hand. Charge nurse went into the room and saw lab tech still in the room and noticed a tape at the back of the left hand. He/She was informed that no blood draws from the left arm but he/she said he/she saw the sign after he/she drew the blood. Supervisor and DON made aware. Checked blood draw site for swelling or bleeding, none noted at 7:30 AM. (Family member) will be notified. On December 16, 2013, a blood draw was done from the left hand, despite signage posted in the resident ' s room. As a resolution to the lab draw from the left hand that occurred on December 16, 2013, was to place an arm band with Restricted Extremity printed in black and placed on Resident #1 ' s left wrist. According to the nurses ' notes and staff interviews, the arm band was not on Resident #1 ' s wrist from July 2 through July 4, 2014. Subsequently, a lab draw from the left hand was done on July 2, 2014. Accord… | 2017-02-01 |
| 1474 | 1474 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 157 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff and resident interview for one (1) of 37 sampled residents, it was determined that facility staff failed to notify the physician when a second area of skin impairment was first noted on Resident #23's left buttocks. The findings include: Through staff interview it was determined facility staff observed a new wound on Resident # 23 ' s left buttock on the weekend of May 9 to 10, 2015; however, notification to a physician or nurse practitioner was not made. Treatment orders for management of the wound were initiated on May 13, 2015 (approximately 4 days later) after the area was assessed as a stage 3 pressure ulcer during routine wound rounds by the Nurse Practitioner. On May 13, 2015 (Wednesday) incontinence care was observed for Resident #23. It was noted that the resident had two (2) dressings on his/her left buttock and one (1) on the right buttock all initialed by a licensed nurse and dated May 12, 2015. A review of the most recent Skin Condition Report dated May 4 and 7, 2015 revealed that Resident #23 had two (2) wounds: left buttock (abscess) and right buttock (abrasion). There was no documentation of a second skin integrity concern on the left buttock as observed on May 13, 2015. Subsequent to the observation of incontinence care on May 13, 2015 the following progress notes were recorded. An Interdisciplinary Progress Note dated May 13, 2015 at 11:15 AM, by the Nurse Practitioner Student revealed the following, . Pt. (patient) has not been out of bed .Skin breakdown - wound care rounds - new orders. L (left) Buttock abscess 2 x 1 x .01cm healing; R (right) buttock 1.5 x 2.5 x .01 cm unstageable, L buttock Stage III 2 x 1 x .01cm .ordered alternating pressure mattress . A review of the Nurse Practitioner ' s note dated May 13, 2015 (no time indicated) revealed, . Abscess to L butt is healing s/p antbx (antibiotics) - has new pressure ulcers - will order alternating pressure mattress and PT … | 2017-02-01 |
| 1475 | 1475 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 167 | C | 0 | 1 | X0E311 | Based on observation and staff interview for six (6) of six (6) areas in which the facility posts the survey results, it was determined that facility staff failed to ensure that the survey results were located in an accessible location as evidenced by unavailable survey results in the lobby area of the facility and a lack of signage to indicate the availability and location in five (5) of five (5) resident care units. The findings include: A tour of the facility to confirm the availability of the survey results was conducted with Employee # 1 on May 21, 2014 at approximately12:10 PM. Entrance- A sign posted in the lobby area indicated that the survey results were available at the front desk, however Employee #1 could not locate them. Unit 1A, first floor- The survey results were located in a common area at the entrance of Unit 1A and were readily avialble but there was no notice posted to indicate the availability or location. Unit 2A, second floor- The survey results were found at the nursing station on 2A, however there was no notice posted to indicate the availability or location. Unit 2B, second floor- The survey results on 2B were placed in a common area at one (1) of two (2) entrances to the unit, however there was no notice posted to indicate the availability or location. Unit 3A, third floor- The survey results on 3A were placed in a common area at one (1) of two (2) entrances to the unit, however there was no notice posted to indicate the availability or location. Unit 3B, third floor- The survey results on 3B were placed in a common area at one (1) of two (2) entrances to the unit, however there was no notice posted to indicate the availability or location. These findings were confirmed by Employee # 1 who was present at the time of the observations. | 2017-02-01 |
| 1476 | 1476 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 174 | D | 0 | 1 | X0E311 | Based on observations, resident and staff interviews for two (2) of 37 sampled residents, it was determined that facility staff failed to provide a private area when residents can make and receive telephone calls without being overheard. Residents' # 66 and #164 The findings include: 1. Facility staff failed to provide Resident #66 a private area to make and receive telephone calls without being overheard. A resident interview was conducted on May 12, 2015 at approximately 4:35PM. In response to a query, Do you have privacy when on the telephone? The resident responded, No and added that everyone can hear his/her conversations. The telephone for resident use was located on a wall directly across from the nursing station on Unit 1A. The telephone was also located in an area where calls can be overheard by residents, staff and visitors. A face-to-face interview was conducted on May 18, 2015 with Employee #4 at approximately 3:00PM. He/she acknowledged the aforementioned findings. 2. Facility staff failed to provide Resident #164 a private area to make and receive telephone calls without being overheard. A resident interview was conducted on May 13, 2015 at approximately 4:26PM. In response to a query, Do you have privacy when on the telephone? The resident responded, No and added that everyone can hear his/her conversations. The telephone for resident use was located on a wall directly across from the nursing station on Unit 1A. The telephone was also located in an area where calls can be overheard by residents, staff and visitors. A face-to-face interview was conducted on May 18, 2015 with Employee #4 at approximately 3:00PM. He/she acknowledged the findings. | 2017-02-01 |
| 1477 | 1477 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 225 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for 16 of 46 Resident/Family Communication forms reviewed, it was determined that facility staff failed to implement policies and procedures to ensure that allegations of mistreatment and/or abuse were reported to the State Agency. The findings include: The Code of Federal Regulations 483.13 (b) defines abuse as: Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. (42 CFR 488.301) This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all residents, even those in a coma, cause physical harm, or pain or mental anguish. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident, such as telling a resident that she will never be able to see her family again. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. A review of the facility ' s Resident/Family Communication forms revealed 46 forms that were recorded as concerns. 16 of the 46 forms identified as concern revealed allegations of mistreatment and/or abuse by staff that ranged from failure to provide timely incontinent care, rough handling, speaking in a harsh tone to missing property. Exampes of allegations are as follows: 1.Relative reported to facility on December 8, 2014 that their (mother/father) was crying and holding the call bell because no one came to assist their (mom/dad.) It was reported by staff that they … | 2017-02-01 |
| 1478 | 1478 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 226 | E | 0 | 1 | X0E311 | Based on record review and staff interview of the facility's policy regarding Abuse and Neglect, it was determined that facility staff failed to develop specific procedures to ensure that allegations of mistreatment, neglect and/or abuse are thoroughly investigated, the means by which residents would be protected from further abuse and that the allegations are reported to the State Agency. The findings include: A review of the facility ' s policy on Abuse and Neglect lacked evidence of a systematic process for staff to follow in the event of alleged abuse. For example, under the facility ' s Abuse policy Number TX- .97, section VI Protection; protect residents from harm during an investigation, lacked evidence of specific procedures that staff should follow to protect the resident(s) in the event of an allegation of abuse. A face-to-face interview was conducted with Employee #1 on May 21, 2015 at approximately 3:30 PM who confirmed the abuse policy had been provided to the survey team. Facility staff failed to develop abuse policies with specific procedures for staff to follow in the event of allegations involving mistreatment, neglect and/or abuse. | 2017-02-01 |
| 1479 | 1479 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 241 | E | 0 | 1 | X0E311 | Based on observations and staff interview for three (3) of 37 sampled residents, it was determined that facility staff failed to ensure a resident's dignity was promoted as evidenced by, failing to enhance dignity during dining for one (1) resident and failing to knock before entering one (1) resident ' s room and maintain an environment free of signage with personal information for (1) one resident ' s #200 # 157 and #162. The findings include: 1. Facility staff failed to provide an environment of dining with dignity for Resident #200. During the lunch observation conducted on May 11, 2015 at approximately 1:30 PM, facility staff was observed using table where Resident# 200 was seated as a central location area for sanitizing their hands and dispensing hand wipes to sanitize other residents hands prior to serving their meals. These activities continued as Resident #200 sat eating his/her meal. During a second breakfast observation on May12, 2015 at approximately 8:50 AM Resident #200 was sitting alone eating his/her meal, as the facility staff use the area as central location for sanitizing their hands and dispensing hand wipes to sanitize other residents hands prior to serving their meals. A face-to-face interview was conducted with Employee #8 on March 12, 2015 at approximately 09:00 AM regarding the aforementioned observation. Immediately, Employee #8 instructed staff to remove items from the residents table acknowledging the findings. The observation was made on May 12, 2015 at approximately 09:00 AM. 2. Facility staff failed to knock and await permission prior to entering Resident #157 ' s room during an isolated observation. On May 13, 2015 at approximately 10:30 AM Employee #35 entered Resident #157 ' s room without knocking. A face-to-face resident interview was in progress and Resident # 157 immediately stated this happens all the time . A face-to-face interview was conducted on May 13, 2014 with Employee # 8 at approximately 12:30 PM. A query was made regarding the facility's practice when needing to e… | 2017-02-01 |
| 1480 | 1480 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 248 | D | 0 | 1 | X0E311 | Based on observation, record review staff and resident interview for one (1) of 37 sampled residents, it was determined that facility staff failed to provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and psychosocial well-being for Resident #19 who sat idle and not participating in activities. The findings include: A face-to-face interview was conducted with Resident #19 on May 12, 2015 at approximately 10:05 AM. The following questions were asked followed by the resident ' s response: Do the activities meet your interests? He/she replied, Some of them. Are the activities provided as often as you would like, including on weekends and evenings? He/she replied, Yes, but they are the same thing. Does staff provide items so you can do activities on your own, like books or cards? No On May 15, 2015 Resident #19 was observed sitting idle on Unit 2B in his/her wheel chair at the table where he/she eats his/her meal. The television was on however the volume low from on Friday May 15, 2015 from 10:00 AM - 1:00 PM. At no time was the resident offer an activity by the Certified Nurse Aides assigned to provide care on the unit. On Monday, May 18, 2015 at approximately 10:15 AM Employee # 6 was asked who was providing activities to the resident today. He/she stated, there is no activity aide on duty today (Monday, May 18, 2015), (he/she) worked the weekend. On Monday, May 18, 2015 from 10:15 AM to 11:30 AM; and from 2:00 PM to 4:30 PM. The resident was observed sitting idle at no time was the resident offer an activity by the CNAs on the unit. A face-to-face interview was conducted with Employee # 24 on Tuesday May 19, 2015 at approximately 11:15 AM. He/she stated, I was off on Friday (May 15, 2015) and Monday (May 18, 2015) . A face-to-face interview was conducted on May 21, 2015 at 10:26 AM with Employee # 28. At this time he/she was made aware of the concerns related to the lack of activities provided to Resident #19 on Unit 2B. Employee #28 acknow… | 2017-02-01 |
| 1481 | 1481 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 253 | E | 0 | 1 | X0E311 | Based on observations made during an environmental tour of the facility on May 15, 2015 at approximately 11:30 AM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by broken slats from window blinds in three (3) of 45 resident's rooms, marred walls in five (5) of 45 resident's rooms, marred entrance doors in seven (7) of 45 resident's rooms, loose wallpaper in the hallways of unit 2B, paint peeling from the ceiling above the resident ' s bed, clear pieces of tape stuck in several areas in the ceiling of room #251 and a missing floor tile in the bathroom of room #251, one (1) of 45 resident's rooms surveyed. The findings include: 1. There was one (1) broken slat from one (1) of one (1) window blind in room #105, two (2) broken slats from one (1) of two (2) window blinds in room #144 and one (1) broken slat from one (1) of two (2) window blinds in room #249, three (3) of 45 resident's rooms surveyed. 2. Walls in five (5) of 45 resident's rooms were marred including rooms #123, #144, #237, #249 and #256 and entrance doors in seven (7) of 45 resident's rooms were marred including rooms #104, #105, #106, #115, #116, #202B and #207B. 3. The wallpaper hanging in the hallways of unit 2B was loose in several areas. 4. The paint was peeling off an area from the ceiling above the resident's bed in room #251B and there were multiple pieces of clear tape stuck to other areas in the ceiling, one (1) of 45 resident's rooms surveyed. 5. There was a floor tile missing in the bathroom of resident room #251 on May 19, 2015 at approximately 12:05 PM, one (1) of 45 resident's rooms surveyed. These observations were made in the presence of Employee #11 and Employee #12 who acknowledged the findings. B. Based on observation and staff interview for one (1) of 37 residents it was determined that facility staff failed to decrease the spread of disease causing organisms as evidence by oxygen tubing lying uncovered on … | 2017-02-01 |
| 1482 | 1482 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 256 | D | 0 | 1 | X0E311 | Based on observation and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to ensure adequate lighting in the resident ' s room closet. Resident #106 The findings include: A resident room observation was conducted on May 15, 2015 at approximately 10:00 AM. The closet light bulb failed to illuminate when activated. A face-to-face interview was conducted with Employee #6 on May 22, 2015 at approximately 11:30 AM. Employee made an attempt to turn the light on by pulling the light string. The light did not illuminate. Employee #6 acknowledged the findings at the time of the observation. | 2017-02-01 |
| 1483 | 1483 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 272 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A.Based on record review and staff interview for six (6) of 37 sampled residents, it was determined that facility staff failed to code the residents Quarterly (Minimum Data Set (MDS) for Other Health Conditions, to accurately complete the quarterly MDS to include a history of fall for two (2) residents; for one (1) resident who used a wheel chair for mobility and was admitted with an active [DIAGNOSES REDACTED]. Residents' #23, #125, #139, #161, #216 and #241. The findings include: 1. Facility staff failed to accurately code the quarterly MDS to include a history of fall's for Resident #23. Resident #23 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of an Incident Report dated February 10, 2015 revealed the following, Resident called, upon entering the room immediately after answering call, found resident sitting on the floor and leaning on wheel chair. Assessment conducted (he/she) verbalized sliding off the wheel chair. Denies pain, denies hitting head. ROM (range of motion) within normal limit, no apparent injury noted. Remain alert and oriented at this time. A review of the care plan initiated on February 12, 2015 revealed the following, Problem Statement - Resident was observed sitting on the floor on 2/10/2015. No injuries noted; Interventions and approaches - Resident will be transferred with a mechanical lift at all times by nursing staff, and will be assisted on a bed pan as needed. A review of the quarterly MDS dated [DATE] revealed the following: Under Section J (Health Conditions) the resident was coded for having no falls since admission/entry or reentry or prior assessment. A review of the medical record showed that facility staff did not accurately code the quarterly MDS to include a fall that the resident sustained [REDACTED]. An interview was conducted with Employee #6 on May 15, 2015 at 4:30 PM. He/she acknowledged the findings. 2. Facility staff failed to accurately code Resident #125's admission Minimum Data Se… | 2017-02-01 |
| 1484 | 1484 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 279 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to develop a care plan with goals and approaches for one (1) resident ' s [DIAGNOSES REDACTED].# 4 The findings include: Facility failed to develop a care plan with goals and approaches for the care of a resident diagnosed with [REDACTED].#4 A review of the physician's order [REDACTED]. A review of the plan of care for Resident #4 lacked evidence that a care plan with goals and approaches was developed to address resident #4 ' s [DIAGNOSES REDACTED]. A face-to-face interview with Employee #6 was conducted on May 19, 2015 at approximately 3:00 PM. He/she reviewed the care plans and acknowledged that a care plan for [MEDICAL CONDITION] was not initiated for Resident #4. The record was reviewed on May 19, 2015. | 2017-02-01 |
| 1485 | 1485 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 280 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 37 sampled residents, it was determined that facility staff failed to review and revise resident care plans to reflect an integrated approach with the participation of hospice, the facility, and the resident or representative to the extent possible for (2) residents; and to address one (1) resident ' s activity needs. Residents ' #109, 120 and 216. The findings include: 1.Facility staff failed to review and revise Resident # 109 ' s care plan for hospice to reflect an integrated approach with the participation of hospice, the facility and the resident or representative to the extent possible. A review of the Physician order [REDACTED].`April 2015 directed: Admit to Hospice for End Stage [MEDICAL CONDITION] (Chronic Obstructive [MEDICAL CONDITION]) start date (November 11, 2014). A review of the residents care plan revealed a care plan for Resident is Hospice Care with goals and approaches initiated February 10, 2015. However, the care plan lacked specific identification of the disciplines responsible for the approaches/interventions with hospice, the facility, resident or the responsible party. Facility staff failed to review and revise the resident ' s care plan for hospice to reflect an integrated approach with the participation of hospice, the facility and the resident or representative to the extent possible. The record was reviewed on May 22, 3015. 2. Facility staff failed to updated the care plan with appropriate goals and approaches to address the resident ' s activity needs for Resident #120. A review of the clinical record revealed that the Activities care plan was last updated on May 3, 2015. Revealed Problems: Patient is in an adjustment period due to recent admission to facility for rehab service. However, Resident #120 was admitted to the facility on [DATE] and has resided in the facility for approximately two years. In addition, the Evaluation of goals and approaches re… | 2017-02-01 |
| 1486 | 1486 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 282 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to implement toilet training as scheduled for one (1) resident with urinary incontinence. Resident #139 . The findings include: 1. Facility staff failed to follow toileting program for Resident # 139. A review of the resident's clinical record revealed that Resident #139 ' s Admission Observation Form dated November 24, 2014 revealed that the resident was occasionally incontinent of bowel and bladder and was on a urinary toileting program. A review of the Incontinent of urine care plan dated March, 10, 2015 revealed the following: Toileting Program: toilet resident upon rising, after meals, before bedtime, and ask/offer resident toilet throughout the day. A review of the residents Bowel & Bladder Risk assessment dated [DATE] revealed: Bladder Control Status as occasionally incontinent, Score 8 (Moderate Restorative Potential), 04/03/2015 Toileting programs selected (none were indicated) A review of the ADL Recordings by resident dated March 31 through - April 28, 2015 revealed resident was not toileted as care planned after meals upon rising and at bedtime. The scheduled unit meal times were as follows: 7:30 AM Breakfast 12:15 PM Lunch 4:30 PM Dinner A review of the ADL Recordings by Resident (Activities of Daily Living) for dates May 1, 2015 through May 14, 2015 revealed Resident # 139 was toileted at the following times: May 1, 2015 -7:05 PM May 2, 2015 -2:07 AM 10:58 AM/8:01 PM May 3, 2015 2:07 AM/10:52 AM/7:32 AM May 4 2015-2:18 AM/2:16 PM/7:33 PM May 5, 2015 -2:15 PM-8:37PM May 6, 2015-3:05 AM-2:33 PM-8:36 PM-2:33AM- May 7, 2015 2:39 PM/8:39 PM- May 8, 2015 10:48 AM- 8 12PM/*:16 PM/ May 9, 2015 12:15 PM-10:06 PM- May10, 2015 12:59 PM-1:49 PM-8:47 PM May 11, 2015 - 2;42 AM 2:45 PM-7:30 PM May 12, 2015-2:55 AM-2:09 PM-8:04 PM- May 13, 2015-2:19 AM 9:36 PM May 14, 2015- 2:35 AM 1:46 PM There was no evidence the facili… | 2017-02-01 |
| 1487 | 1487 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 309 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for four (4) of 37 sampled residents, it was determined that facility staff failed to ensure that an initial nursing assessment for hospice was a part of the residents clinical active file for two (2) residents; assess for pain, monitor effectiveness of pain medication, and modify the approaches to pain as necessary for one (1) resident; ensure that the physician's order [REDACTED]. Residents #109, #120 #125 and #216. The findings include: 1.Facility staff failed to ensure that the initial nursing assessment for hospice was a part of Resident #109 active clinical file. A review of the Physician order [REDACTED]. Further review of the clinical record lacked evidence of the Admission-Initial and Comprehensive Assessment. A face-to-face was conducted on May 21, 2015 at approximately 11:00 AM with Employees #6, 17, 18, and 19. After review of the A review of the clinical all acknowledged the finding. 2. Facility staff failed to assess for pain, monitor effectiveness of pain medication, and modify the approaches to pain as necessary for Resident #120. Resident #120 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Resident #120 on May 18, 2015 at 11:50 AM. The resident stated, Right now my pain is a 6/10 (range 0 is the lowest and 10 is the highest). I always have pain. The medication helps but it doesn ' t relieve the pain. The nurses don ' t ask me if I am in pain. This interview was held in the presence of Employee #6. A review of the quarterly MDS dated [DATE] section J0300 (Pain Presence) Have you had pain or hurting at any time in the last 5 days? The section was coded as No . Section I8000 (Additional active diagnoses) is coded for other Chronic pain. A review of the clinical record revealed a care plan updated on May 3, 2015 for Pain Management. The Problem is alteration in comfort related chronic pain (lower extremities). Resident has … | 2017-02-01 |
| 1488 | 1488 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 312 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to ensure that Resident #55, who is unable to carry out activities of daily living the necessary services received grooming to his/her face and nails. The findings include: According to the annual Minimum Data Set, dated dated dated [DATE] Resident #55 was coded as totally dependent with one (1) person physical assistance in personal hygiene under Section G110 Activities of Daily Living (ADL) Assistance. The resident ' s [DIAGNOSES REDACTED]. On May 13, 2015 at approximately 3:11 PM Resident #55 was observed in the dayroom/television room seated in a recliner chair. His/her chin had gray hair on both sides and his/her finger nails on the left hand were observed with a dark substance underneath the nail beds. Employee #6 was present at the time of the observation and acknowledged the findings. There was no evidence that facility staff carried out activities of daily living necessary to maintain good grooming for Resident #55. | 2017-02-01 |
| 1489 | 1489 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 314 | G | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview it was determined facility staff failed to notify a resident ' s physician/nurse practitioner when a new wound was identified at Stage III and failed to obtain orders for the immediate care and treatment of [REDACTED]. Resident #23. The findings include: Through staff interview it was determined facility staff observed a new wound on Resident # 23 ' s left buttock on the weekend of May 9 to 10, 2015; however, notification to a physician or nurse practitioner was not made. Treatment orders for management of the wound were initiated on May 13, 2015 (approximately 4 days later) after the area was assessed as a stage 3 pressure ulcer during routine wound rounds by the Nurse Practitioner. On May 13, 2015 (Wednesday) incontinence care was observed for Resident #23. It was noted that the resident had two (2) dressings on his/her left buttock and one (1) on the right buttock all initialed by a licensed nurse and dated May 12, 2015. A review of the most recent Skin Condition Report dated May 4 and 7, 2015 revealed that Resident #23 had two (2) wounds: left buttock (abscess) and right buttock (abrasion). There was no documentation of a second skin integrity concern on the left buttock as observed on May 13, 2015. Subsequent to the observation of incontinence care on May 13, 2015 the following progress notes were recorded. An Interdisciplinary Progress Note dated May 13, 2015 at 11:15 AM, by the Nurse Practitioner Student revealed the following, . Pt. (patient) has not been out of bed .Skin breakdown - wound care rounds - new orders. L (left) Buttock abscess 2 x 1 x .01cm healing; R (right) buttock 1.5 x 2.5 x .01 cm unstageable, L buttock Stage III 2 x 1 x .01cm .ordered alternating pressure mattress . A review of the Nurse Practitioner ' s note dated May 13, 2015 (no time indicated) revealed, . Abscess to L butt is healing s/p antbx (antibiotics) - has new pressure ulcers - will order alternatin… | 2017-02-01 |
| 1490 | 1490 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 323 | E | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made on during the survey, it was determined that facility staff failed to ensure resident ' s environment was free of accident hazards as evidenced by a electric space heater observed in one (1) residents room; an extension cord observed in use to supply power to the fish tank on unit 2B, a wood plank lifted from the floor in the hallway of the nursing unit and a splintered headboard that was attached to the wall in one resident's room. The findings include: 1. On May 18, 2015 at 10:50 AM, a space heater was observed on the floor of the resident ' s room between the bed and the window. The heater was plugged into the wall and actively circulating warm air about the room in one (1) of one (1) space heater observed. Employee #6 was present at the time of the observation and acknowledged the finding. 2. On May 13, 2015 at approximately 2:30 PM a extension cord was observed plugged in to the wall and to the fish tank located on unit 2B. This observation was made in the presence of Employee # 12, who acknowledged the finding. 3. On May 13, 2015 at 11:00 AM a wood plank was observed lifted from the floor in the hallway nearby the storage closet on unit 2B. Employee #6 was present at the time of the observation and acknowledged the findings. 4. On May 13, 2015 a headboard attached to the wall in one (1) residents room was observed to be splintered. A tour of Resident #162's room was conducted on May 13, 2015 at approximately 10:30 AM. It was observed that the wall in the resident ' s room adjacent to the residents bed (towards the foot of the bed) was splintered wood. A face-to-face interview was conducted with Employee #6 on May 22, 2015 at approximately 11:30 AM. After making an observation of the room, he/she acknowledged the findings. B. Based on observation, record review, and staff and resident interview it was determined that facility staff failed to keep resident free from falls as evidenced by failure to transfer resi… | 2017-02-01 |
| 1491 | 1491 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 329 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 37 sampled residents, it was determined that facility staff failed to clarify the indication of use for the medication [MEDICATION NAME] ([MEDICATION NAME]) with the physician. Resident #133 The findings include: Facility staff failed to clarify the indication of use for the medication [MEDICATION NAME] with physician. Resident #133 During an Unnecessary Medication Review, it was noted on the Interim Order Form signed and dated April 7, 2015 that Resident #133 was placed on MPAP ([MEDICATION NAME] Extra Strength) Tablet 500mg, Give 2 tablets by mouth every eight hours at 06:00, 14:00, 22:00, for [MEDICAL CONDITION] A review of Admission and Annual Physical Examination Form signed and dated August 15, 2014 revealed the following [DIAGNOSES REDACTED]. A review of the Interdisciplinary progress note revealed Resident #133 ' s 60 day review dated April 6, 2015 at 1:40PM reads as follow: HIV,[MEDICAL CONDITIONS], CKD stage 2, HTN, Frequent falls, (R) tib/fib fracture s/p (status [REDACTED].#6 reads Back pain + (positive), pt (patient) c/o (complain of) mild intermittent achy pain, start scheduled Tylenol Q (every) 8 hours. A review of the Minimum Data Set (MDS) dated [DATE] revealed in Section 1 Active [DIAGNOSES REDACTED]. Review of the EMAR (Electronic Medication Administration Record) for the month of April, 2014 revealed electronic order for [MEDICATION NAME] 500mg: Give 2 tablets by mouth every eight hours (from Pharmacy) at 06:00, 14:00, 22:00, for [MEDICAL CONDITION]; from Nurse practitioner, order enter by registered nurse. The medical record lacked evidence of facility staff clarifying the indication for use of the MPAP with the physician's for a [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee #4 on May 20, 2015 at approximately 2:30 PM. After review of the above, Employee #4 acknowledged the findings. The record was reviewed on May 20, 2015. | 2017-02-01 |
| 1492 | 1492 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 364 | D | 0 | 1 | X0E311 | Based on observation and resident interview for one (1) of 37 sampled residents, it was determined that a resident was served food that was palatable and attractive, as evidenced by failure to ensure that the Resident #19 received a breakfast meal that taste good an looked appetizing. The findings include: A face-to-face interview was conducted with Resident # 19 on May 12, 2015 at approximately 10:17 AM. The resident was asked, Does the food taste good and looks appetizing? He/she replied, No indeed. The resident was observed having his/her breakfast on May 21, 2015 at 9:50 AM. The resident was asked how your breakfast is. He/she replied by shaking his/her head, then touched the banana and said it ' s (the banana) rotten. On the resident ' s plate was, the edge of toast, a half eaten boiled egg, and an off white and deep brown colored banana. This observation was made in the presence of Employee #6 who acknowledged the findings. | 2017-02-01 |
| 1493 | 1493 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 371 | E | 0 | 1 | X0E311 | Based on observations made on May 11, 2015 at approximately 9:15 AM, it was determined that the facility failed to prepare and store food under sanitary conditions as evidenced by foods such as one (1) of four (4) bags of cheddar cheese, one (1) of one (1) pan of tomato, ham and turkey breast chunks, one (1 ) of one (1) pan of roast beef slices, one (1) of one (1) pan of chopped meat, one (1) of one (1) pan of noodles and carrots slices, one (1) of one (1) pan of shredded lettuce and one (1) of one (1) pan of onions and celery slices that were stored in the walk-in refrigerator undated, a soiled floor in the main kitchen, dry food storage and dishwashing area, two (2) of two (2) convection ovens that were soiled on the inside and outside and one (1) of one (1) plate warmer with clean plates that was left uncovered. The findings include: 1. One (1) of four bags of cheddar cheese, one of (1) pan of tomato, ham and turkey breast chunks, one (1 ) of one (1) pan of roast beef slices, one (1) of one (1) pan of chopped meat, one (1)of one (1) pan of noodles and carrots slices, one (1) of one (1) pan of shredded lettuce and one (1) of one (1) pan of onions and celery slices were stored in the walk-in refrigerator undated. 2. The entire kitchen floor, including the floor in the dry food storage area and in the dishwashing area was marred, scarred and discolored. 3. The inside and the outside of two (2) of two (2) convection ovens were soiled. 4. One (1) of one (1) plate warmer with clean plates was observed uncovered in the main kitchen. These observations were made in the presence of Employee #9 and/or Employee #10 who acknowledged the findings. | 2017-02-01 |
| 1494 | 1494 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 428 | D | 0 | 1 | X0E311 | Based on record review and staff interview for one (1) of 37 sampled residents, it was determined that the facility failed to maintain a resident ' s highest practicable level of functioning related to medication therapy to the extent possible as evidenced by its failure to provide a licensed pharmacist's review of each resident's regimen of medications at least monthly. Resident #4. The findings include: A review of the clinical record revealed a Medication Regimen Review (MRR) sheet from November 6, 2014 through May 6, 2015. The clinical record lacked a MRR sheet for the months of May 2014 through October 2014. A face to face interview with Employee #6 was conducted on May 20, 2015 at approximately 3:00 PM. When queried regarding the missing MRR sheet he/she responded That he/she did not know where the previous MRR was and said pharmacy takes care of that . The record was reviewed on May 20, 2015. | 2017-02-01 |
| 1495 | 1495 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 431 | D | 0 | 1 | X0E311 | Based on observation, record review and staff interview, it was determined that facility staff failed to maintain medication storage in accordance with accepted professional principles as evidenced by: one (1) blister packet medication was stored beyond the expiration date for one (1) resident; two (2) unit refrigerator temperature log sheet was not consistently check and record once a day and the Controlled Drug Count Verification (shift count sheet for Narcotics) was reconciled by two nurses ' signatures. The findings include: Facility failed to maintain medication storage in accordance with accepted professional principles as evidenced by: 1. One (1) blister packet medication was stored beyond the expiration date for one resident. (Resident #95) On May 21, 2015 at approximately 11:40AM one (1) blister packet medication was found stored beyond the expiration date. The medication storage observations revealed the following: On Unit 3A Resident# 95 had 28 tablets of Oxycodone 5mg stored for use. The expiration date on the package was March 2015. The observation was made in the presence of Employee #8. He/she acknowledged the findings. 2. Two (2) unit refrigerator temperature log sheet was not consistently check and record once a day. (Unit 3A and 3B) On May 21, 2015 at approximately 11:45AM a review of the Refrigerator Monitoring Log on unit 3A and 3B revealed that the temperature recordings were left blank indicating not completed on the following month and days: Unit 3B: February 15, 16 17, 26, 2015 Unit 3A: April 12, 26, 27, 2015 Unit 3A: May 2, 13, 2015 Unit 3B: May 1, 3, 4, 8, 9, 20, 2015 There was no documented evidence that facility staff consistently monitored the temperature of the Medication refrigerator located in the nurse ' s station medication rooms on units 3A and 3B. 3. Facility staff failed to ensure that the Controlled Drug Count Verification (shift count sheet for Narcotics) was reconciled by two nurses ' signatures. (Unit 2B) A review of the Controlled Drug Count Verification records conducted… | 2017-02-01 |
| 1496 | 1496 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 441 | D | 0 | 1 | X0E311 | Based on observation and staff interview, it was determined that facility staff failed to help decrease the spread of infection as evidenced by having multiple unlabeled bed pans in one (1) resident ' s bathroom; failed to sanitize hands in between feeding and assisting two (2) residents; and failed to ensure the toilet seat riser was stored properly when not in use. The findings include: 1.Facility staff failed to help decrease the spread of infection by not clearly labeling three (3) bed pans in Resident #162 ' s bathroom that was shared with another resident. An observation of resident #162's bathroom was conducted on May 13, 2015 at approximately 9:45 AM. It was observed that two (2) pink bedpans were observed stored in the resident ' s room. One (1) behind the commode on the floor; one (1) on the grab bar behind the toilet and one (1) white fracture bedpan observed stored on the grab bar to the left of the toilet. A face-to-face interview was conducted on May 22, 2015 at approximately 1:00 PM with Employee #6. At that time a second observation was made of the resident ' s bathroom. After making the observation Employee #6 acknowledged the finding. 2.Facility staff failed to decrease the spread of infection as evidenced by not sanitizing hands in between assisting two (2) residents. Employee #20 was observed on May 21, 2015 at approximately 12:45 PM feeding a male resident. Employee #20 observed that another resident at the table needed assistance, stopped and assisted that resident (touching the hands of the resident) and returned back to feeding the first male resident without sanitizing his/her hands. A face-to-face interview was conducted with Employee #6 on May 22, 2015 at approximately 11:40 AM. After review of the above scenario, he/she acknowledged the findings. 3. Facility staff failed to ensure the toilet seat riser was stored properly when not in use. On May 19, 2015 at 12:05 PM a tour of Resident #23 ' s bathroom was conducted. At this time a white toilet seat riser was observed on the floor in th… | 2017-02-01 |
| 1497 | 1497 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 456 | E | 0 | 1 | X0E311 | Based on observations and interview on May 11, 2015 at approximately 9:10 AM, it was determined that the facility failed to maintain essential equipment in safe, operating condition as evidenced by: one (1) of one (1) toaster oven that lacked a temperature adjustment knob, one (1) of two (2) hand washing sinks housing with a loose cover, one (1) of one (1) ice machine with a cracked plastic lid, one (1) of two (2) non-functioning garbage disposals and one (1) of one (1) reach-in box that has been out of order for more than a year. The findings include: 1. One (1) of one (1) toaster oven in the main kitchen was without a temperature adjustment knob. 2. The cover to the housing of one (1) of two (2) hand washing sinks hung loosely from the sink and needed to be repaired. 3. The plastic cover on the inside of the lid of one (1) of one (1) ice machine was cracked. 4. One (1) of two (2) garbage disposals was not functioning. 5. One (1) of one (1) reach-in box has been broken for over a year. During an environmental tour of the main kitchen on May 11, 2015 at approximately 9:30 AM, Employee #9 was asked about the reach-in box that was no longer operational and he/she responded that it had been out of service for over a year. These observations were made in the presence of Employee #9 who acknowledged the findings. | 2017-02-01 |
| 1498 | 1498 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 463 | E | 0 | 1 | X0E311 | Based on an observations made on May 15, 2015 at approximately 11:30 AM, it was determined that the facility failed to maintain the call bell communication system in good working condition as evidenced by: call bell pull cords that were too short in three (3) of 45 resident's bathrooms, a non-functioning call bell in one (1) of 45 resident's rooms and a missing call bell in one (1) of 45 resident's rooms. The findings include: 1. Call bell pull cords located in the bathroom of resident rooms #135, #146, and #227 were too short and could not function as intended in three (3) of 45 resident's rooms surveyed. 2. The call bell in resident rooms #78, #150 did not emit an alarm when tested , two (2) of 45 resident's rooms surveyed. 3. The call bell in resident room #214A was missing, one (1) of 45 resident's rooms surveyed. These observations were made in the presence of Employee #11 and/or Employee #12 who acknowledged the findings. | 2017-02-01 |
| 1499 | 1499 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 492 | E | 0 | 1 | X0E311 | Based on record review and staff interview of the facility's policy regarding Abuse and Neglect, it was determined that facility staff failed to implement policies and procedures to ensure that allegations of mistreatment and/or abuse were acted on, investigated, resolved and reported to the State Agency. The findings include: 22b DCMR 3232.4, Incident Reporting- Stipulates, Each incident shall be documented in the resident's record and reported to the licensing agency within forty-eight (48) hours of occurrence, except that incidents and accidents that result in harm to a resident shall be reported to the licensing agency within eight (8) hours of occurrence. A review of the facility ' s Policy No: TX - .97 P&P (Policy and Procedure) Name: Abuse and Neglect identified the Resident Abuse and Neglect policy and procedures 7 (seven) step approach, however, the policy lacked procedures that allegations of mistreatment and/or abuse were acted on, investigated, resolved and reported to the State Agency. A review of page 2 of 4 of the Abuse and Neglect Policy, Procedure: lacked evidence of procedures to on how to protect the resident. A face-to-face interview was conducted with Employee #1 on May 21, 2015 at approximately 3:30 PM. A query was made regarding the policy on Abuse and Neglect the complete policy. Employee #1 responded yes , this is all we have. Facility staff failed to implement policies and procedures to ensure that allegations of mistreatment and/or abuse were acted on, investigated, resolved and reported to the State Agency. | 2017-02-01 |
| 1500 | 1500 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-05-22 | 514 | D | 0 | 1 | X0E311 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for three (3) of 37 sampled residents, it was determined that facility staff failed to consistently document characteristics and status of abrasions, open areas, and pressure ulcers for two (2) residents with multiple areas of skin impairment; and accurately document (1) one resident's race. Residents' #23, 139 and 241. The findings include: 1. Facility staff failed to consistently document the status of wounds/skin impairment for Resident #23. A review of the facility ' s documents revealed licensed nurses recorded wound/skin assessments weekly on a form entitled Skin Condition Report Without Images. The Skin Condition Reports Without Images for Resident #23 were reviewed and revealed that licensed staff recorded conflicting documentation related to wound assessments as follows: May 13, 2015 at 2:58 PM, Skin and Wound Update to Site - 340. Present on the Left Lower Buttocks is a Abrasion. The following findings were documented, Staging, Stage 3, Length in cm=2, Width in cm =1, Depth in cm=0.1, no odor is apparent, no drainage is apparent, Recent changes were made to the treatment orders for this site. This wound was not present on admission, Wound base is visible. Other color in wound base = 100%. General comments: New treatment order . May 13, 2015 at 3:09 PM New (2nd recording) for Site 340. Present on the Left Lower Buttocks is a Pressure Ulcer. The following findings were documented, Unable to accurately stage - Slough and/or Eschar covered, Length in cm = 2, Width in cm = 1, Depth in cm = 0.1, no odor is apparent, no drainage is apparent, Wound base is visible, Slough tissue type = 100%, General Comments: New orders given . Facility staff failed to consistently document characteristics and status of skin impairment for Resident #23. 2. Facility staff failed to consistently document characteristics and status of abrasions, pressure ulcers and open areas for Resident #241 with multiple areas of s… | 2017-02-01 |
| 1501 | 1501 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-08-20 | 329 | D | 1 | 0 | OLV611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that facility staff failed to monitor INR levels. Subsequently, INR level was found to be 8 (normal range between 2-3). The findings include: Resident #1 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment with an assessment reference date of July 1, 2015, Resident #1 scored 3/15 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 0-7 suggests that the resident is severely cognitively impaired. Resident #1 was assessed as requiring supervision for eating, extensive assistance for bed mobility and totally dependent for transfers, dressing, personal hygiene, toileting and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Resident #1 was admitted to the hospital on July 11, 2015. According to the hospital discharge summary dated July 23, 2015, the resident had an INR of 8 (desired range 2-3) on admission to the hospital (July 11, 2015). A review of the nursing home record revealed that Resident #1 had been receiving [MEDICATION NAME] since admission on January 5, 2015. INR levels had been drawn frequently and the [MEDICATION NAME] dosage was adjusted as indicated by the blood test results. On June 17, 2015, the INR was 1.70 and the [MEDICATION NAME] was increased to 3 mg daily. A repeat INR level was scheduled for June 24, 2015. However, the test drawn was a PTT not an INR. A notation on the laboratory result indicated PT/INR ordered will add on. There was no evidence in the record that that an INR level was drawn after June 24, 2015. A review of the June and July 2015 Medication Administration Records, revealed that the resident received [MEDICATION NAME] 3 mg daily from June 17, 2015 through July 11, 2015. According to the nurse practitioner ' s order dated April 30, 2015: [MEDICATION NAME] 100 mg PO BID x 7 days for ab… | 2017-02-01 |
| 1502 | 1502 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2015-08-20 | 428 | D | 1 | 0 | OLV611 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that the pharmacist failed to identify that an INR level was not drawn on June 24, 2015 and after Doxycycline therapy was initiated. The findings include: Resident #1 was admitted to the hospital on July 11, 2015. According to the hospital discharge summary dated July 23, 2015, the resident had an INR of 8 (desired range 2-3) on admission to the hospital (July 11, 2015). A review of the nursing home record revealed that Resident #1 had been receiving Coumadin since admission on January 5, 2015. INR levels had been drawn frequently and the Coumadin dosage was adjusted as indicated by the blood test results. On June 17, 2015, the INR was 1.70 and the Coumadin was increased to 3 mg daily. A repeat INR level was scheduled for June 24, 2015. However, the test drawn was a PTT not an INR. A notation on the laboratory result sheet indicated PT/INR ordered will add on. There was no evidence in the record that that an INR level was drawn after June 24, 2015. The pharmacist reviewed the resident ' s medication regimen review as follows: January 26, 2015 February 18, 2015 March 31, 2015 April 23, 2015 May 6, 2015 June 6, 2015 July (unable to read), 2015 There were no recommendations made by the pharmacist regarding the resident ' s medications for any of the above cited dates. According to the Chronological Record of Medication Regimen Review, the pharmacist reviewed the resident ' s medications on July (unable to read date), 2015. The pharmacist wrote 6/17 - 1.70 INR (unable to read). The pharmacist circled NR (no recommendations). The pharmacist failed to identify that an INR was not drawn on June 24, 2015. According to the nurse practitioner ' s order dated April 30, 2015: Doxycycline 100 mg PO BID x 7 days for abscess. A nurse ' s note dated April 30, 2015 at 11:34 PM, Alert and verbally responsive. Denies pain. Tolerated all due medications Started on ABT Doxycycline 100 m… | 2017-02-01 |
| 1503 | 1503 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 246 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations made on February 22, 2016 between 11:30 am and 3:00 pm, it was determined the facility failed to accommodate one resident ' s needs as evidenced by a call bell cord in one (1) of 38 resident rooms that was too short to be easily accessible. The findings include: The call bell cord in the bathroom of room [ROOM NUMBER] was too short to be easily accessible for the Resident in one (1) of 38 resident rooms surveyed. These observations were made in the presence of Employees' #22 and #23 who acknowledged the findings. | 2017-02-01 |
| 1504 | 1504 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 253 | E | 0 | 1 | 2L6211 | Based on observations made on February 22, 2016 between 11:30 AM and 3:00 PM, it was determined the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior as evidenced by loose wallpaper on two (2) of five (5) resident care units, soiled bathroom vents in three (3) of 38 resident rooms, a loose cove base in one (1) of 38 resident rooms and marred walls in three (3) of 38 resident rooms. The findings include: 1. The wall paper was loose, unglued from the walls in unit 2b across from rooms #203 and #204, between rooms #207 and #208, on unit 2a between rooms #237 and #238 and next to room #247. 2. Bathroom vents were soiled on the inside and outside in three (3) of 38 resident rooms. (#123, #207 and #212). 3. The cove base close to the bathroom was hanging loose and needed to be secured in one (1) of 38 resident rooms (#208). 4.Walls were marred in three (3) of 38 resident rooms (#207, #212, #255). These observations were made in the presence of Employee #22 and Employee #23 who acknowledged the findings. | 2017-02-01 |
| 1505 | 1505 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 272 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview for one (1) of 17 sampled residents, it was determined that facility staff failed to accurately code Section J, ' Special Treatments and Programs ' of the Significant Change Minimum Data Set (MDS) for Resident #24. The findings include: A review of Resident #24 ' s clinical record revealed his/her [DIAGNOSES REDACTED]. A ' Hospice Recertification ' form signed by the physician on November 4, 2015 included a statement that read, Based on the patient ' s [DIAGNOSES REDACTED]. A review of the Significant Change MDS completed November 17, 2015, with an assessment reference date (ARD) of November 10 - 17, 2015 revealed that Section J, J1400, Prognosis was coded no, indicative that the medical record does not contain physician documentation that the resident is terminally ill. On February 25, 2016 at approximately 2:50 PM a face-to-face interview was conducted with Employee #9, the MDS Coordinator, regarding the coding of section J1400, Prognosis the significant change MDS dated [DATE]. Upon secondary review, Employee #9 acknowledged the aforementioned findings. | 2017-02-01 |
| 1506 | 1506 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 279 | E | 0 | 1 | 2L6211 | Based on record review and staff interview for nine (9) of 17 Stage 2 sampled residents and three (3) supplemental residents, it was determined that facility staff failed to develop comprehensive care plans with measurable goals, timetables and specific interventions to manage the discharge needs of residents. Residents' #20, 24, 37, 56, 62, 69, 84, 88, and 112. The findings include: The provider ' s ' Notice of Closure ' A review of the facility ' s documents revealed the facility provided a Notice of Closure letter signed by the Chief Executive Officer and dated November 3, 2015 (initial notification was September 15, 2015) addressed to all residents (and/or responsible parties) residing in the facility that read: This letter serves each of you as your official notice of closure and the need to transfer or discharge to another location. Final closure will be December 15, 2016 .We will assure the continuity of services by providing the receiving facility with assessment and care plan, and for discharge, by arranging for those services required by the post discharge plan . Pursuant to The District of Columbia ' s Transfer/Discharge statute - D.C. Law 6-108, the Nursing Home and Community Residence Facilities Protections Act, DC Code 44-1003.01 .Residents residing at the facility will undergo involuntary discharge as follows: Chapter 10. Nursing Homes and Community Residence Facilities Protections. Subchapter III. Discharge, Transfer, and relocation of residents. 44-1003.01. Grounds for involuntary discharge, transfer, or relocation by facility. (a) Unless a resident and his or her representative consent otherwise, a facility may discharge the resident, transfer the resident to another facility, or relocate the resident from one part or room of the facility to another only: .(5) If the facility is closing or officially reducing its licensed capacity . 1. Facility staff failed to develop a discharge plan of care for Resident #20. A review of Resident #20's clinical record revealed a social service progress note dat… | 2017-02-01 |
| 1507 | 1507 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 284 | E | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for seven (7) of seven (7) discharged sampled residents, it was determined that facility staff failed to develop a post-discharge plan of care to ensure the individual ' s needs will be met after discharge from the facility into the community. Residents ' #12, #40, #96, #100, #101, #107, and #118 The findings include: A letter sent to the residents from the Chief Executive Officer and Administrator of the facility dated November 3, 2015, regarding the facility ' s closure stipulated; This letter is to establish the next steps as required by the District of Columbia Model Resident Transfer and Discharge Plan for Nursing homes When you and your representative are ready to move, we will provide you with the following information: A written statement of the medical assessment and evaluation, and post-discharge plan of care . A review of the District of Columbia official Code 2001 Edition, Division VIII. General Laws Title 44. Charitable and Curative Institutions. Subtitle I. Health Related institutions. Chapter 10. Nursing Homes and Community Residence Facilities Protections. Subchapter III. Discharge, Transfer and Relocation of Residents. 44-1003.04 Discussion and Counseling Before a resident is voluntarily or involuntarily discharged , transferred to another facility or reacted within a facility, a facility representative shall discuss the reasons for the move with the resident and his or her representative and shall answer any questions they must have about the move or the written notice they received pursuant to 44-1003.02 (a). The contents of the discussion shall be summarized in writing, include the names of the individuals involved in the discussion and be made a part of the resident ' s clinical record. In addition, the facility representative shall strongly recommend and offer to provide counseling services to the resident and his or her representative before the move. If the resident has reques… | 2017-02-01 |
| 1508 | 1508 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 309 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 17 stage 2 sampled residents, it was determined that facility staff failed to provide the necessary care and services to ensure residents attain or maintain the highest practicable state of well-being as evidenced by failure to perform pain assessments and re-assessments prior to and after the administration of as needed (prn) pain medication and failed to clarify physician ' s orders for the prescribed indication for use of [MEDICATION NAME] ([MEDICATION NAME] medication) for one (1) resident; and failed to administer a pneumococcal vaccine and follow through with timeliness on a physician ' s order for a speech evaluation for one (1) resident. Resident ' s #24, and #92. The findings include: 1. Facility staff failed to perform pain assessments prior to and following the administration of as needed (prn) pain medication ([MEDICATION NAME] - an Opioid [MEDICATION NAME] medication.) and failed to clarify physician ' s orders for the prescribed 'indication for use' of [MEDICATION NAME]. A Facility staff failed to conduct pain assessments prior to and following the administration of prn [MEDICATION NAME]. A review of the facility policy titled, Pain Management Revised July, 2015 states under the section titled ' Purpose, ' To relieve or decrease the level of the resident ' s/patient ' s pain. 1). Pain assessment .3) pain evaluation . In section ' II ' titled ' Pain Assessment - Administration of Pain Medications. ' a. Prior to administration of PRN (as needed) medications for pain, the licensed nurse must assess the resident ' s/patient level of pain using a quantitative scale .A Progress Note with the quantitative pain measurement documented in the note, must be entered in the EMR (electronic medical record) under the category of Pain management. One hour (or earlier if the resident/patient voices concern) following the administration of the PRN pain medication the licensed nurse must re… | 2017-02-01 |
| 1509 | 1509 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 323 | G | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observations, record review and staff interview for one (1) of 17 sampled residents, it was determined that facility staff failed to ensure that the resident environment remained as free from accident hazards as is possible and that adequate supervision was provided in order to enhance safety and reduce the risk of an accident as evidenced by one (1) resident who sustained a fall with injury. Resident #54 The findings include: On February 26, 2016 at approximately 9:00 AM, Employee #2 informed the survey team that Resident #54 sustained a fall with injury this morning and was sent to a local hospital for emergency treatment via ambulance. A review of the facility ' s incident report titled, Incident Details, documented by nursing staff, dated February 26, 2016 at 4:48 AM read as follows: Around 2:48 AM there was a sound from resident ' s room, writer and the assigned CNA (certified nursing assistant) rushed to the room where resident was found on the floor in sitting position leaned on (his/her) right side noted with blood all over (his/her) face. Resident alert and oriented x3 (person, place, time), resident stated to writer (he/she) fell from chair and hit (his/her) head on the floor. Supervisor made aware and came to the unit. Resident noted with laceration on (his/her) forehead .and laceration on left eyebrow pressure dressing applied to the sites. Resident denied back and neck pain at this time, pupils react to light equal. Active and passive ROM (range of motion) with normal limit to all extremities. Dr (named) notified and new order received to transfer resident to hospital ER (emergency room ' for further evaluation and treatment. 911 (emergency medical services) called and resident was transferred to hospital (named) ER at around 3:25 AM . {SIC} On February 26, 2016 at approximately 9:30 AM, an observation was conducted of Resident #54 ' s room. The room was observed cluttered. Multiple items were noted scattered along th… | 2017-02-01 |
| 1510 | 1510 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 329 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 17 stage 2 sampled residents, it was determined that facility staff failed to ensure that one (1) resident was free of unnecessary medications as evidenced by a failure to consistently monitor psychopharmacological medications for Resident #24. The findings include: A review of the clinical record revealed that Resident #24 ' s [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#24 ' s medication regimen included the following: 1. [MEDICATION NAME] (anxiolytic) 0.25mls (milliliters) sublingual (under the tongue) every 12 hours for anxiety/[MEDICAL CONDITION]. 2. [MEDICATION NAME] (antidepressant) 20mg (milligram), 1 tablet by mouth, 1 time a day for depression A review of the Electronic Medication Administration Record [REDACTED]. [MEDICATION NAME] was given every day at 9:00AM between February 1, 2016 and February 24, 2016. A review of the clinical record lacked documented evidence of behavior monitoring in the section of the Electronic Medical Record (EMR) dedicated to documenting behaviors, or in the nursing progress notes. On February 24, 2016 at approximately 2:10PM, a face-to-face interview was conducted with Employee #11. When asked what behaviors were exhibited by Resident #24, he/she stated that the resident is agitated at times, (uses profanity) and calls the staff names. When asked where that information is documented Employee #11 stated that they don ' t always document those behaviors. On February 24, 2016 at approximately 2:25 PM a face-to-face interview was conducted with Employee #4 regarding the aforementioned findings. He/she acknowledged the findings. There was no evidence that facility staff monitored Resident #24 ' s target symptoms; therapeutic effectiveness and/or potential adverse consequences of the resident ' s anxiolytic and antidepressant medications. The record was reviewed on February 24, 2016. | 2017-02-01 |
| 1511 | 1511 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 334 | E | 0 | 1 | 2L6211 | Based on record review and staff interview for 15 of 17 Stage 2 sampled residents and 35 supplemental residents, it was determined that facility staff failed to ensure that the immunization program included a method to track the status of pneumococcal immunization for eligible residents and determine those residents who might benefit from pneumococcal revaccination. Residents' #7, 20, 24, 26, 39, 54, 69, 72, 74, 75, 84, 86, 92, 101 and 112. Supplemental residents' # 1, 5, 16, 18, 23, 27, 28, 30, 31, 42, 43, 44, 45, 48, 49, 50, 51, 52, 55, 56, 58, 59, 62, 63, 64, 68, 71, 81, 87, 91, 97, 106, 113, 115 and 117. The findings include: A review of the facility ' s Immunization Protocol (Effective date July 2002 and last reviewed July 2012) revealed: Policy: The(NAME)Home will provide education to residents and family regarding the importance of the pneumococcal .vaccines as well as administration and documentation of vaccines. Procedure: 4) .If the consent box is not checked then the admitting nurse of Clinical Manager contacts the responsible party to determine why the resident is not to receive the immunizations. The Clinical Manager or admitting nurse will discuss the importance of the vaccination program to the health of the resident, of other residents, and the staff in the building. If the answer is still no, the admitting nurse or Clinical Manager contacts the medical staff so that the further discussions with the resident/responsible party take place. 5) When the resident receives the vaccinations this information is entered into the resident immunization record. 6) Resident immunization status will be reviewed every 60 days. Their status will be placed on the physicians round sheet .8) Weekly monitoring of the immunization status as updated on the HCFA 672 Form . A review of the facility ' s immunization program lacked evidence that resident ' s pneumococcal vaccination status was monitored on an ongoing basis. Additionally, there was no evidence that a monitoring mechanism was in place to determine whether or… | 2017-02-01 |
| 1512 | 1512 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 371 | E | 0 | 1 | 2L6211 | Based on observations that were made during a tour of the dietary services on February 22, 2016 at approximately 9:45 AM, it was determined that the facility failed to store, prepare and serve food under sanitary conditions as evidenced by nine (9) of nine (9) plates of chicken salad, one (1) of one (1) tray of macaroni salad, a quarter pan of cooked broccoli and one whole pan of cooked chicken breast that were not dated , eight (8) of eight (8) steam wells and two (2) of two (2) grease fryers that were soiled, a leaking inlet valve to one (1) of one (1) juice machine, a leaking control valve to one (1) of one (1) tilt skillet, a missing handle to one (1) of one (1) tilt skillet and a broken plastic cover to one (1) of one (1) sugar storage bin. The findings include: 1. Nine (9) of nine (9) plates of chicken salad with tomatoes and crackers, stored in refrigerator box #7 were not dated. 2. One (1) of one (1) tray of macaroni salad, a quarter pan of cooked broccoli and one whole pan of cooked chicken breast stored in the walk-in refrigerator were not dated. 3. Eight (8) of eight (8) steam wells from two (2) of two (2) steam tables were soiled with food residue. 4. Two (2) of two (2) grease fryers were soiled with leftover fried food residue. 5. The water inlet valve to one (1) of one (1) juice machine was leaking. 6. The on/off control valve to one (1) of one (1) tilt skillet was leaking. 7. The handle from the lid cover to one (1) of one (1) tilt skillet was missing. 8. One (1) of two (2) plastic covers to one (1) of one (1) sugar storage bin was broken and a piece of that cover was missing. 9. Two (2) of two (2) scoop storage containers were soiled at the bottom with excess sugar and flour. 10. Two (2) of two (2) convection ovens were soiled with burnt food deposits. These observations were made in the presence of Employee #20 and Employee #21 who acknowledged the findings. | 2017-02-01 |
| 1513 | 1513 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 386 | D | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview for one (1) of 17 stage 2 sampled residents, it was determined the physician failed to review the total program of care for Resident #69 as evidenced by a failure to act on a consulting specialists ' recommendation to initiate rehabilitation services. The findings include: Random observations of Resident #69 during the survey period, February 22 through 26, 2016 revealed the resident stayed mostly in his/her room in the bed. The resident was interviewed during the Stage I phase of the survey process and verbalized he/she was able to make his/her needs known. During the interview, he/she stated that staff would assist him/her to get out of bed when he/she wanted; however had no desire to get out of bed at the time of the interview on February 23, 2016 at approximately 1:00 PM. According to the physician ' s progress note dated November 24, 2105, Resident #69 ' s [DIAGNOSES REDACTED]. A psychiatric follow up note dated February 9, 2016 included the following: (Resident named) .has noted recently that (he/she) has spent more time in (his/her) room than usual. While (he/she) will say that (he/she) goes out once a day the staff reports that (he/she) is resistant to get dressed and go outside of (his/her) room despite many invitations and encouragements. (Resident) denies being depressed .(he/she) is pleasant most of the time but that (he/she) does not like to change (his/her) routine recommendations .if available, would restart the physical therapy with (Resident) as (he/she) will otherwise develop muscle weakness . A review of physician progress notes [REDACTED].#69. There was no documentation by the physician/medical to indicate that he/she was aware of the recommendation or that he/she disagreed with the recommendation. A face-to-face interview was conducted with Employee #19 on February 25, 2016 at approximately 3:00 PM. In response to a query regarding rehabilitative services for Resident #69… | 2017-02-01 |
| 1514 | 1514 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 431 | D | 0 | 1 | 2L6211 | Based on observation and staff interview it was determined that the facility failed to ensure that medications were not stored beyond the manufacturer's expiration date in one (1) of three (3) Medication Rooms observed. The findings include: On February 25, 2016 at approximately 11:00 AM, during an inspection of Unit 1A (the locked medication refrigerator), three (3) of three (3) boxes of Pneumovac- Pneumococcal Vaccine Polyvalent- 10 single- dose- 0.5ml (millimeters) vials were observed with an expiration date of January 13, 2016 on each of the vials. The observation was made in the presence of Employee #18 on February 24, 2016 at approximately 4:10 PM. He/she acknowledged the findings and removed the vials from the refrigerator. | 2017-02-01 |
| 1515 | 1515 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 441 | D | 0 | 1 | 2L6211 | Based on observation and staff interview for one (1) of 17 sampled residents it was determined that facility staff failed to manage wound treatment supplies in a manner equipment as to reduce and/or prevent the potential for cross contamination during a wound treatment; and facility staff failed to ensure that the Infection Control Program included a consistent and systematic collection, analysis, interpretation and dissemination of data to identify infections and infection risks in the facility. Resident #24 The findings include: 1. Facility staff failed to manage wound treatment supplies in a manner as to reduce and /or prevent the potential for cross contamination during wound care for Resident #24. On February 26, 2016 at approximately 10:15AM, a wound care observation was conducted. During this time Employee #12 removed clean uncovered/unwrapped cotton tipped applicators from a package and placed them uncovered into a cardboard box containing Non-Woven Sponges. The clean tips of the applicators were touching the inside surface of the box. When Employee #12 started to perform the dressing change to the resident ' s right hip, he/she removed the cotton tip applicators from the box and placed them on an open, clean gauze pad wrapper. The employee then applied Skin integrity Hydrogel dressing (a gel that is used to maintain a moist wound environment) to the wound on the resident's right hip. He/she then used the cotton tip applicator to spread the gel around the wound. On February 26, 2016 at approximately 11:00AM a face-to-face interview was conducted with Employee #12 regarding clean technique and the potential for cross contamination. He/she acknowledged the findings and stated that the cotton tipped applicators should have been placed on the clean gauze when removed from the package. Facility staff failed to manage wound treatment supplies in a manner as to reduce and/or prevent the potential for cross contamination during wound care. 2. Facility staff failed to ensure the implementation of an infection cont… | 2017-02-01 |
| 1516 | 1516 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 463 | D | 0 | 1 | 2L6211 | Based on observations made on February 22, 2016 between 11:30 AM and 3:00 PM, it was determined that the facility failed to maintain resident call systems as evidenced by inoperative call bells in two (2) of 13 resident rooms. The findings include: Call bells did not function as intended in two (2) of 38 resident rooms (#115 and #127). These observations were made in the presence of Employee #22 and Employee #23 who acknowledged the findings. | 2017-02-01 |
| 1517 | 1517 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-02-26 | 514 | E | 0 | 1 | 2L6211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for three (3) of 17 sampled residents and three (3) supplemental residents, it was determined that facility staff failed to ensure that a hospice discharge note was readily available in the active clinical record for Resident #24 and that the clinical record included documented evidence of discharge planning activities for two (2) residents. Additionally, facility staff failed to ensure that eight (8) of eight (8) glucometers (a medical device for measuring blood glucose) were set with the current date(s) and time. Resident's #20, 24 and 88. The findings include: 1. Facility staff failed to document evidence of measures related to facilitating Resident #20 ' s involuntary discharge from the facility. A review of the facility ' s documents revealed the facility provided a Notice of Closure letter signed by the Chief Executive Officer and dated November 3, 2015 (original notification was dated September 15, 2015) addressed to all residents (and/or responsible parties) residing in the facility that read: This letter serves each of you as your official notice of closure and the need to transfer or discharge to another location. Final closure will be December 15, 2016 .We will assure the continuity of services by providing the receiving facility with assessment and care plan, and for discharge, by arranging for those services required by the post discharge plan . A social service progress note dated September 18, 2015 at 3:21 PM read, Spoke with (family member) about the closing of (Facility named). S/he is interested in working with (family member) to find a place for (him/her) to live SE (southeast), NE (northeast) are a possibility. Also (local facility) is an option. Will continue to work with them to explore a safe discharge plan. A social service progress note dated November 9, 2015 at 4:37 PM read, The formal letter to resident notifying (gender) of closure of (name of facility) in Dec… | 2017-02-01 |
| 1518 | 1518 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-09-26 | 371 | D | 1 | 0 | S7P711 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews and record review for Resident #1, it was determined that facility staff failed to prepare food in a safe manner as evidenced by several pieces of a foreign object found in pureed meat on September 21, 2016. The findings include: Resident #1 was born on August 13, 1933 and was admitted to the facility on [DATE]. According to the Minimum Data Set assessment with an assessment reference date of August 2, 2016, Resident #1 was assessed as having severely impaired cognitive skills for daily decision making in Section C (Cognitive Patterns). Resident #1 was assessed as requiring extensive assistance for bed mobility, transfers, dressing, eating, toileting, and personal hygiene and totally dependent for bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. On September 21, 2016 during the evening meal, it was noted that several small pieces of a hard, plastic, grey foreign substance were observed in the pureed meat. Employee #1 was notified and called Employee #2 to the unit. Both employees observed the hard, grey plastic foreign objects in the pureed meat. Face-to-face interviews were conducted with Employees #1 and #2 on September 26, 2016 between 5:00 PM and 5:30 PM who acknowledged the presence of several small grey plastic foreign objects in the pureed meat on September 21, 2016. Employee #1 instructed facility staff to check the other residents ' with pureed food for the small plastic grey foreign objects. There were eight (8) total residents who received pureed food. Two (2) additional trays were found with small plastic grey foreign objects. According to Employee #1, neither resident had been fed prior to the discovery of the hard, grey plastic foreign objects found in the food. The food was discarded and fresh food was prepared for the three (3) residents identified by facility staff with small plastic grey foreign objects in their food. The blender that was used to prep… | 2017-02-01 |
| 1519 | 1519 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-10-20 | 203 | D | 1 | 0 | L5DV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that facility staff failed to issue a transfer/discharge notice for two (2) hospitalization s. The findings include: Resident #1 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment with an assessment reference date of June 11, 2016, the resident was assessed with [REDACTED]. Resident #1 was assessed as being totally dependent for all Activities of Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. A review of the resident ' s record revealed that the resident had been hospitalized on [DATE], September 4, 2016, and September 9, 2016. According to the MDS (Minimum Data Set) 3.0 User ' s Manual , page 2-9, Discharge refers to the date a resident leaves the facility .There are two types of discharges - return anticipated and return not anticipated. A Discharge assessment is required with both types of discharges .Any of the following situations warrant a discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds .resident is admitted to a hospital (regardless of whether the nursing home discharges or formally closes the record.) . A transfer/discharge notice was issued on September 6, 2016 by facility staff for the hospitalization of September 4, 2016. There were no discharge notices issued for the hospitalization s of August 6, 2016 and September 7, 2016 to the QIES to Success data base. According to the QIES to Success website: : Welcome to QIES to Success, the custom web-based system developed to assist in managing and monitoring information and applications within the Quality Improvement Evaluation System. To find information in a quick and efficient manner, visit the QIES to Success pages anytime you need to find information on CASPER, MDS, OASIS, RAVEN, HAVEN, and ASPEN, to name a few. A face-to-face interview was conducted with Employee #1 on October… | 2017-02-01 |
| 1520 | 1520 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-10-20 | 286 | D | 1 | 0 | L5DV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, facility staff failed to compete and transmit discharge assessments to the MDS data base for Resident #1 and Resident #2. The findings include: According to the MDS (Minimum Data Set) 3.0 User ' s Manual , page 2-9, Discharge refers to the date a resident leaves the facility .There are two types of discharges - return anticipated and return not anticipated. A Discharge assessment is required with both types of discharges .Any of the following situations warrant a discharge assessment, regardless of facility policies regarding opening and closing clinical records and bed holds .resident is admitted to a hospital (regardless of whether the nursing home discharges or formally closes the record.) . According to the QIES to Success website: : Welcome to QIES to Success, the custom web-based system developed to assist in managing and monitoring information and applications within the Quality Improvement Evaluation System. To find information in a quick and efficient manner, visit the QIES to Success pages anytime you need to find information on CASPER, MDS, OASIS, RAVEN, HAVEN, and ASPEN, to name a few. A review of Resident #1 ' s record revealed that the resident had been hospitalized on [DATE], September 4, 2016, and September 9, 2016. A review of the QIES to Success website, MDS 3.0 viewer, revealed that a discharge assessment was not completed for Resident #1for any of the above cited hospitalization dates. A review of Resident #2 ' s clinical record revealed that the resident was transferred to another nursing facility on August 15, 2016. A review of the QIES to Success website, MDS 3.0 viewer, revealed that a discharge assessment was not completed for Resident #2 for the above cited transfer date. A telephone interview was conducted with Employee #2 on October 18, 2016 at 12:25 PM. He/she acknowledged that the discharge notice was not transmitted to the MDS data base. The records were reviewed Octo… | 2017-02-01 |
| 1521 | 1521 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2016-10-20 | 287 | D | 1 | 0 | L5DV11 | Based on record review and staff interview for four (4) residents, it was determined that facility staff failed to submit the discharge assessments to the QIES to Success data base in a timely fashion. Residents #3, 4, 5, and 6. The findings include: According to the MDS 3.0 User ' s Manual , page 5-3, Submission Time Frame for MDS Records , directed .Transmission requirements apply to all MDS 3.0 records used to meet both Federal and state requirements .Discharge (assessments) - Final Completion or event date Z0500B (Date RN signed assessment as complete) +14 (days). 1. A review of Resident #3 ' s record revealed a Z0500B date of July 19, 2016. The submission date was August 9, 2016, 22 days later. 2. A review of Resident #4 ' s record revealed a Z0500B date of August 16, 2016. The submission date was September 23, 2016, 39 days later. 3. A review of Resident #5 ' s record revealed a Z0500B date of August 18, 2016. The submission date was September 23, 2016, 37 days later. 4. A review of Resident #6 ' s record revealed a Z0500B date of July 25, 2016. The submission date was September 23, 2016, 61 days later. A telephone interview was conducted with Employee #2 on October 18, 2016 at12:25 PM. He/she acknowledged that the discharge notice was not transmitted to the MDS data base. The records were reviewed October 14, 2016. | 2017-02-01 |
| 1715 | 1715 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-06-03 | 323 | G | 1 | 0 | HX0R11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for Resident #1, it was determined that inadequate supervision was given to the resident who was improperly transferred and subsequently was found to have a fractured right distal third of the tibia and fibula. The findings include: Resident #1 was born on March 15, 1935 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], Resident #1 was assessed as having short and long-term memory problems with severely impaired cognitive skills for daily decision-making in Section C (Cognitive Patterns). Resident #1 was assessed as being totally dependent for all Activities of Daily Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated April 20, 2013 at 1:06 AM: At 10 PM CNA assigned to the patient called me to come to the patient ' s room to show me the right foot and ankle. He stated that as he/she was doing his/her ADLs he/she noticed a change in (Resident #1 ' s) facial look as he/she was turning him/her. (The CNA) noticed his/her right foot and ankle to be slightly bent. The patient was assessed by (writer) and Nursing Supervisor. The right foot and ankle did slightly bend inside. NP notified and responded with new orders. The right foot is not discolored or swollen upon assessment. Daughter is aware. This is for 4/19/13 at 10 PM. A telephone interview was conducted with Employee #1 on May 2, 2013 at 11:25 AM. Employee #1 was asked about the above concerns and stated, (Resident #1) was sitting in a geri-chair and he/she was making a face like he/she was going to cough. He/she makes that face all the time. That was something normal for him/her. I put him/her back to bed with the Hoyer lift about seven o ' clock (7:00 PM). I had to do it by myself because I couldn ' t find any help. The transfer was okay. Nothing happened during the transfer. I positioned him/her on his/her right side. I put p… | 2016-06-01 |
| 1742 | 1742 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 241 | D | 0 | 1 | RSE411 | Based on an isolated observation for one (1) of 41 sampled residents, it was determined that facility staff failed to promote dignity for one (1) resident as evidenced by the observation of a paper towel applied proximal to the resident ' s ear as a skin protectant. Resident #43 The findings include: Facility staff failed to promote dignity for Resident #43. The resident was observed on February 20, 2013 at approximately 11:30 AM seated in a wheelchair in the common area of the nursing unit with portable oxygen infusing via nasal cannula. The nasal cannula was applied as prescribed, to the resident ' s nares and secured behind his/her ears. A paper towel was observed resting loosely and unevenly along the tubing of the nasal cannula proximal to the resident ' s right ear. At the time of the observation, Employee #5 was queried as to the purpose of the paper towel observed proximal to the resident ' s ear. He/she stated that the resident had a tendency to have skin break down behind the ears secondary to the oxygen tubing and that the paper towel served to protect the resident ' s skin. He/she added, 4 x 4 gauze pads are supposed to be used (instead of the paper towel). A face-to-face interview was conducted with Employee #17, the licensed staff assigned to Resident #43, on February 20, 2013 at approximately 2:30 PM. In response to a query regarding the paper towel observed proximal to Resident #43 ' s ear, he/she replied that the paper towel served to protect the skin behind the resident ' s ear from breaking down. However, he/she stated that gauze sponges are usually used to protect the skin behind the resident ' s ear from the oxygen tubing rubbing against it. Facility staff failed to promote dignity for Resident #43 as evidenced by the observation of a paper towel applied proximal to the resident ' s ear as a skin protectant. | 2016-04-01 |
| 1743 | 1743 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 246 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews for two (2) of two (2) resident rooms observed, it was determined that the facility failed to ensure that residents' received services with reasonable accommodations of individual needs as evidenced by two (2) of two (2) call bells were not accessible for communication from the residents' rooms and/or bathrooms. The findings include: 1. Facility staff failed to ensure that the call bell system in resident room was accessible for communication from the resident. The call bell was not accessible for communication for one (1) of one (1) resident's room [ROOM NUMBER] on February 13, 2013 at approximately 4:37 PM. Resident #20 was observed sitting in his/her chair. The call light was wrapped around the bedrail. The resident was sitting on the opposite side and was not in reach of the call light. Subsequently, the call bell was unwrapped from the bedrail and placed within the resident 's reach. These observations were made in the presence of Employee #6 who acknowledged the findings 2. A resident room observation was conducted on February 14, 2013 at approximately 11:09 AM on 3A in room [ROOM NUMBER]. The following was observed: The resident ' s pull cord in the bathroom was wrapped around the grab bar, tied in a knot, about 12 inches from the floor. The observations were made in the presence of Employees #16 and #32. | 2016-04-01 |
| 1744 | 1744 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 253 | E | 0 | 1 | RSE411 | A.Based on observations made during an environmental tour of the facility on February 13, 2013 at approximately 2:00 PM and on February 14, 2013 at approximately 10:00 AM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior as evidenced by two (2) of four (4) broken window blinds in two (2) of seven (7) resident rooms; a damaged door frame in one (1) of seven (7) residents' rooms, a stained commode in the bathroom of one (1) of seven (7) residents rooms, marred and scarred closet doors in two (2) of seven (7) residents rooms, a pillar and an adjacent wall damaged with numerous holes five (5) in one (1) of seven (7) residents rooms, and peeling wallpaper on both sides of the hallway between rooms #226 and #238. The findings include: 1. Window blinds were broken in rooms #216 and #230, in two (2) of seven (7) residents' rooms. 2. The door frame to the entrance door of room #216 was damaged with a hole on the left side of the frame in one (1) of seven (7) resident's rooms. 3. The bathroom commode was stained in room #257, one (1) of seven (7) resident's rooms. 4. Closet doors in two (2) of seven (7) residents' rooms were marred and scarred (rooms #222 and #223). 5. A pillar in room #237 and the adjacent wall were damaged with holes in one (1) of seven (7) resident's rooms. 6. The wallpaper on both sides of the hallway between rooms # 226 and #238 was peeling off the walls in one (1) of three (3) hallways observed and needed to be repaired. These observations were made in the presence of Employee #6 at approximately 2:00 PM on February 13, 2013 and at approximately 10:00 AM on February 14, 2013. He/she acknowledged the findings. B. Based on observations of 39 randomly selected rooms during an environmental tour of the facility on February 20, 2013 at 10:30 AM, it was determined that the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable in… | 2016-04-01 |
| 1745 | 1745 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 279 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on an observation, record review and staff interviews for three (3) of 41 sampled residents, it was determined that facility staff facility staff failed to obtain specialized rehabilitative services for a resident who had a positive - PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Level II Screen. Resident #2. an integrated care plan for hospice services for one (1) resident; and to address a swallowing impairment or potential for aspiration for one (1) resident. Residents #2, #9, and #164. The findings include: 1. Facility staff failed to obtain specialized rehabilitative services for a resident who had a positive - PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Level II Screen. Resident #2. A review of the medical record for Resident #2 identified that the resident was admitted to the facility in March 25, 1968. Review of the PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Screen dated January 20, 2008, identified the resident as positive for Mental [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set with an ARD (Assessment Reference Date) of November 15, 2012 identified in Section I the following Diagnoses: [REDACTED]., Slow transit constipation, other drug allergy, Unspecified Infantile [MEDICAL CONDITION], Mild Intellectual Disabilities (Mental [MEDICAL CONDITION]). Review of the Care Plan Face Sheet identified that the IDT (Interdisciplinary Team Meeting) was conducted on November 15, 2012. Further review of the care plans lacked evidence of a care plan with goals and approach to address Resident #2's positive screen for Mental [MEDICAL CONDITION]. A face-to-face interview was conducted with Employee #4 on February 14, 2013 at approximately 5:10 PM. After a review of the care plans, he/she acknowledged the findings. Facility staff failed to develop a care plan with mea… | 2016-04-01 |
| 1746 | 1746 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 309 | E | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for seven (7) of 41 sampled residents, it was determined that facility staff failed to ensure that each resident received and the facility provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by a failure to: consistently assess and monitor the status of altered skin integrity for two (2) residents; follow through on a physician's order [REDACTED]. [REDACTED]. Residents ' #82, 107, 205, 252, 273, 286 and 292. The findings include: 1. A review of the clinical record for Resident #82 revealed facility staff failed to consistently assess and monitor the status of an alteration in skin integrity and failed to follow through on a physician's order [REDACTED]. A. An electronic entry entitled Incident details dated January 2, 2013 at 10:33 PM read: Resident reported with new open area of inner buttock measure 2.5 cm (centimeter) x 2 cm and cluster of small skin open areas at the same site. (physician named) notified, order given to clean open area with soap and water, pat dry, apply [MEDICATION NAME] each shift after each incontinent care. A nurse ' s entry dated January 3, 2013 at 12:25 AM read, (family member named) called and was informed of skin impairment to sacral area. A review of the corrected quarterly Minimum Data Set (MDS) signed January 8, 2013; assessment reference date January 3, 2013 was coded in Section M, Skin conditions that the resident had one (1) Stage 1 pressure ulcer. The clinical record lacked evidence of monitoring and ongoing assessments of the status of the alteration in skin integrity of the sacral area and/or inner buttocks for Resident #82. There was no evidence of documentation regarding the status of the resident ' s altered skin subsequent to the initial assessment on January 2, 2013. An observation of the… | 2016-04-01 |
| 1747 | 1747 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 323 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews for one (1) of 41 sampled residents, it was determined that facility staff failed to ensure that Resident #164 received adequate services /supervision as to promote safe swallowing during a medication administration observation. The findings include: On February 13, 2013 at 9:50 AM a medication administration observation was conduct. Employee # 19 was observed administering oral medications to Resident #164. While at the bedside of the resident, Employee #19 administered medications which included Calcium Carbonate one (1) tablet, Neurontin 100mg two (2) tablets, and Xifaxan one (1) tablet. The Employee gave Resident #164 approximately 50 ml of cranberry juice in a cup with a straw for the resident to swallow his/her medication. The resident drank the cranberry juice by sipping it from the straw. Observed on Resident #164 ' s over-the-bed table was one (1) packet of Instant Food Thickener and one (1) container of Thick and Easy pre-thickened beverage. At no time did Employee # 19 mix the thickener with the cranberry juice that was given to Resident #164 to drink while taking his/her medications. According to the History and Physical dated May 4, 2012 Resident #164 had a [DIAGNOSES REDACTED]. A review of the physician orders [REDACTED]. A review of the Functional Maintenance Program-recommendations dated October 22, 2012 revealed, Referral to restorative nursing for .cue as needed for adherence to safe swallow strategies/aspiration precautions and required diet/liquid consistencies . A review of the Nutritional Assessments dated November 12, 2012 and February 13, 2013 revealed, Current diet order- Mech (mechanical soft, nectar thick, NCS (no concentrated sweets) A review of the Care Plans printed by the facility and those located on the active clinical record revealed that there was no care plan with goals and approaches to address the resident ' s swallowing impairment or potential for aspira… | 2016-04-01 |
| 1748 | 1748 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 329 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 41 sampled residents, it was determined that facility staff failed to ensure that residents were free from unnecessary drugs as evidenced by: failure to clarify two (2) physician 's orders for pain medication, and failed to determine under which condition/s each medication was to be administered for one (1) resident; and facility staff administered an antihypertensive medication outside of the prescribed parameters for one (1) resident. Residents #4 and 286. The findings include: 1. Facility staff failed to determine under which condition/s each pain medication was to be administered to Resident #4. A review of a physician's order [REDACTED]. The first order was [MEDICATION NAME] 325mg 2 tabs (tablets) (650mg) by mouth every four hours as needed for pain . The second order was [MEDICATION NAME]-APAP (n=Acetyl Para Amino [MEDICATION NAME]) 5mg/325mg 2 tabs by mouth every 6 hours as needed for pain . A review of the Medication Administration Record [REDACTED]. The [MEDICATION NAME] was administered 10 times between February 1 and February 18, 2013; once on February 1, 4, 5, 6, 10, 12, 14 and 18 and twice on February 15, 2013. A review of the back of the February 2013 MAR indicated [REDACTED]. The nurses documented the sites of the pain in nine (9) of the 10 instances of administration. The level of the pain and the effectiveness were documented in three (3) of the 10 instances when the medication was administered. A review of the Pain Management Policy, Item number Six (6) under Pain Assessment indicated that Pain assessment includes quantitative and qualitative rating and description using pain scale with 0 - 5 (zero to five) rating. A face-to-face interview was conducted with Employee #6 at approximately 3:15PM on February 20, 2013. The employee was queried regarding the two orders of pain medications prescribed for the resident and the fact that only one medication had been administer… | 2016-04-01 |
| 1749 | 1749 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 371 | E | 0 | 1 | RSE411 | Based on observations made during a tour of Dietary Services on February 19, 2013 at approximately 10:15 AM, it was determined that the facility failed to store, prepare and serve food under sanitary conditions as evidenced by: Four (4) of four (4) hotel pans and 14 of 21 sheet pans that were stored wet and ready for reuse, one (1) of one (1 ) cutting board was observed with an indentation, and two (2) of two (2) convention ovens were observed soiled. The findings include: The following was observed during a tour of the main kitchen: 1. Four (4) of four (4) 4 inch hotel pans were stored wet and ready for reuse 2. 14 of 21 sheet pans were stored wet and ready for reuse 3. A white cutting board was observed with an indentation in one (1) of one (1 ) observed 4. Two (2) of two (2) convention ovens were observed with soiled interiors These observations were made in the presence of Employee # 20. | 2016-04-01 |
| 1750 | 1750 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 406 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 41 sampled residents, it was determined that facility staff failed to obtain specialized rehabilitative services for a resident who had a positive - PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Screen. Resident #2. The findings include: Facility staff failed to obtain specialized rehabilitative services for a resident who had a positive - PASRR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Screen. Resident #2. Review of the PASRR Screen dated January 20, 2008, identified the resident as positive for Mental [MEDICAL CONDITION] and has been referred to the District of Columbia Department of Mental Health for a Level II evaluation. A review of the clinical record revealed a letter dated and written by Employee #10 on May 24, 2012. The letter revealed that Employee #10 had made contact with a representative from the Developmental Disabilities Administration. and (he/she) faxed the information that is required to obtain a Level II screening. Further review of the medical record identified a letter from the Developmental Disabilities Administration Services (no date indicated), addressed to Employee #10 which revealed the following: RE (reference): PASRR Level II Screen for (Resident #2): In response to your request, the following information is necessary for approval: ? A completed PASRR form (attached); ? A current signed physical assessment including (or with appended statement of) justification for necessity of nursing home placement; ? All current physician orders [REDACTED].>? Any other current assessments (e.g., OT (Occupational Therapy), PT (Physical Therapy, psychiatric, nursing etc) which support the necessity of nursing home placement; ? A psychiatric assessment of the patient response to medication if patient seeking level II is currently prescribed any of the following drug group… | 2016-04-01 |
| 1751 | 1751 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 431 | D | 0 | 1 | RSE411 | A. Based on an observations during medication storage review, it was determined that facility staff failed to ensure that intravenous (IV) fluids were not stored beyond the expiration date. The findings include: 1. One (1) of six (6) 5% Dextrose and 0.9% Sodium Chloride Injection USP 1000ml were stored and ready for use, beyond their expiration date of January, 2013. 2. One (1) of two (2) 10% Dextrose Injections 1000 ml had an expiration date of November, 2012 and was stored for use. These observations were made in the presence of Employee #7 at 4:15PM on February 15, 2013 on Unit 3B. B. Based on a medication storage observation of three (3) of five (5) units observed, it was determined that facility staff failed to accurately record the controlled drug sheets verifying the reconciliation of controlled substances; failed to label four (4) of four (4) vials of insulin in two (2) of three (3) medication storage refrigerators; failed to maintain the medication storage refrigerator temperatures between 36 degrees and 46 degrees Fahrenheit and failed to maintain records to identify usage and disposition of a controlled medication. The findings include: 1. Facility staff failed to sign their signatures in the correct columns for Balanced checked by nurse coming on duty and Balance checked by nurse going off duty on the Controlled Drug Count Verification/Shift Count for Narcotics sheet. A medication storage observation was conducted on Unit 2B on February 13, 2013 at approximately 11:25 AM in the presence of Employee #25. A review of the Controlled Drug Count Verification/Shift count sheet for Narcotics sheet, it was observed for February 13, 2013 7:00 AM to 3:00 PM shift that the column titled drug count correct was written yes , Employee #28 ' s name was signed in the coming on duty column and Employee #25 ' s name was signed in the going off duty column. The line just below Employee #28 ' s signature was also Employee #25 ' s signature. Noticing that Employee #25 was delivering morning medications, a query was made r… | 2016-04-01 |
| 1752 | 1752 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 456 | D | 0 | 1 | RSE411 | Based on observations made during a tour of Dietary Services on February 19, 2013 at approximately 10:15 AM, and during a tour of the facility, it was determined that the facility failed to ensure that essential equipment was maintained in safe operating condition as evidenced by one (1) of two (2) ovens were observed with a missing bottom panel exposed wires and two (2) of two (2) personal refrigerators that were not deemed to be in safe operating condition prior to use. The findings include: 1. During a tour of Dietary Services on February 19, 2013 at approximately 10:15 AM, it was determined that the facility failed to ensure that essential kitchen equipment was maintained in safe operating condition as evidenced one (1) of two (2) ovens were observed with a missing bottom panel exposed wires. This observation was made in the presence of Employee #20 who acknowledged the finding. 2. Two (2) of two (2) personal refrigerators were observed in use in resident rooms (#229 and 137) in the absence of a mechanical clearance (deeming the refrigerators safe for use) determined by the facility. The observation was made in the presence of Employees #1 and 14 during an environmental tour of the facility on February 20, 2013. | 2016-04-01 |
| 1753 | 1753 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 463 | E | 0 | 1 | RSE411 | Based on observations and staff interview for five (5) of five (5) resident rooms observed, it was determined that facility staff failed to ensure that the call system in five (5) residents' rooms were functioning to allow communication from the residents to the nurses' station. The findings include: 1. Facility staff failed to ensure that the call bell system in the residents' rooms and/or bathrooms were functioning properly. The call bell in Room #230 did not initiate an audible alarm when tested in one (1) of one (1) resident's room observed on February 14, 2013 at approximately 12:25 PM. Employee #6 stated, the staff probably pulled the call bed cord to reach where the resident was sitting, and this loosened the cord from the wall outlet. Subsequently, the call bell was removed and re- inserted into the wall outlet, which initiated an alarm to the nursing station. 2. Facility staff failed to ensure that the call bell system in the residents' rooms and/or bathrooms were functioning properly in three (3) of five (5) rooms observed. 2A. A resident room observation was conducted on February 13, 2013 at approximately 3:19 PM on Unit 3A in Room 305. The following was observed: When the residents ' call bell was activated (pressed) in the room, the call bell would not sound at the nurses ' station, nor would the light (outside of the room over the door) light up. When an attempt was made to answer the resident from the nurses ' station, the audible voice was not heard in the room. Employee #31 made an attempt to readjust the call bell, but was still unsuccessful in getting the call bell to function properly. This observation was made in the presence on Employee #30 and Employee #31. 2B. A resident room observation was conducted on February13, 2013 at approximately 4:26 PM on Unit 3A in Room #323. The following was observed: When the resident ' s call bell was activated (pressed) in the room, the bell would sound at the nurses ' station. When an attempt was made to answer the resident from the nurses ' station, the a… | 2016-04-01 |
| 1754 | 1754 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 469 | D | 0 | 1 | RSE411 | Based on observation and staff interview it was determined that facility staff failed to maintain an effective pest control program to ensure that the facility is free of pests. The findings include: Flying pests were observed as follows: 1. On unit 1-A at the nursing station in the presence of Employee #4 on February 14, 15 and 19, 2013. 2. In room #102 while observing incontinence care, in the presence of Employee #15 on February 19, 2013. | 2016-04-01 |
| 1755 | 1755 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2013-02-21 | 514 | D | 0 | 1 | RSE411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 41 sampled residents, it was determined that facility staff failed to ensure that one (1) resident's weight was accurately documented in the clinical record. Resident #98. The findings include: According to the clinical record, Resident #98 was admitted to the facility on [DATE] for Physical Therapy, Occupational Therapy and Speech Therapy. A review of the Master problem list revealed resident ' s [DIAGNOSES REDACTED]. A review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of October 25, 2012 revealed Resident #98 was coded under Section K0200 as weighing 160 pounds on admission. The physician's orders [REDACTED]. The unit's Up To Scale Weight Record revealed the following weights: October 18, 2012- 217.7 pounds October 19, 2012 - 157.8 pounds October 24, 2012- 158 pounds October 31, 2012- 159.6 pounds A review of a printout from Optimus (electronic medical record) titled Resident ' s Weight On or after 10/18/12 revealed the following weights: October 18, 2012- 217.7 lbs (pounds) October 24, 2012 - 158 lbs November 7, 2012 - 159 lbs November 14, 2012 - 157.2 lbs An Initial Nutrition Risk Assessment dated October 22, 2012 (no time indicated) revealed: . Interventions - Monitor weight weekly x 4; on mechanical soft d/t (due to) swallowing deficient, po (by mouth intake) good- 75-100 percent of meals, 217.7 (pounds). Over wt (weight) but weight loss not an issue at this point due to age, (no) recent labs, no [MEDICAL CONDITION], no skin openings. Continue to F/U (follow-up), diet meets needs. Facility staff failed to document or address the weight variance of 59.7 pounds; which is indicative of a significant weight change from October 18, 2012 to October 19, 2012. A face-to-face interview was conducted with Employee #7 on February 20, 2013 at approximately 3:30 PM. After reviewing the clinical record; he/stated: The admission weight is not correct, the we… | 2016-04-01 |
| 1973 | 1973 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 166 | D | 0 | 1 | KI3J11 | Based on observations, record review, staff and family interview for one (1) of 50 sampled residents, it was determined that facility staff failed to ensure that a prompt effort was made to resolve a grievance concerning Resident #74's missing eyeglasses. The findings include: During an initial tour conducted on February 21, 2012 at approximately 9:42 AM; Resident #74 was observed sitting in a chair with a breakfast tray in front of him/her. His/her hands were positioned in front of the food on his/her plate; however, he/she was not eating. The resident was queried about why he/she was not eating. He/she responded, I can ' t see. Employee #10 proceeded to ask; where are your glasses? He/she stated, I don ' t know. Another observation was made on February 24, 2012 at approximately 4:30 PM; the resident was lying flat in bed and was not wearing his/her eyeglasses. An interview was conducted with Employee #74 ' s responsible party (RP) on February 22, 2012 at approximately 12:45 PM. He/she stated, This is the second pair of eyeglasses I have brought for (Resident #74). I have not seen his/her eyeglasses since Friday (February 17, 2012). I reported this to (Employee #10). According to the Resident's Property List dated Novevmber 1, 2011, articles retained by resident included glasses and case. A review of the facility's policy titled: Family/Resident Communication Tool indicated that the family/resident will be contacted within five (5) business days with a response and/or resolution. A review of the facility's Communication Forms lacked evidence that a grievance/concern form was initiated as a result of the resident ' s responsible party's verbalized concern to facility management staff. A face-to-face interview was conducted with Employee #10 on February 24, 2012 at approximately 1:15 PM he/she confirmed the RP's reporting of the resident ' s missing eyeglasses. He/she stated, I will follow-up with the RP. The clinical record was reviewed on February 24, 2012. | 2015-09-01 |
| 1974 | 1974 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 224 | D | 0 | 1 | KI3J11 | Based on observations and staff interview, during the environmental tour of the facility on February 29, 2012, it was determined facility staff failed to safeguard one (1) of one (1)resident ' s personal property after death. Resident #F1. The findings include: The policy entitled, Gifts, Gratuities, & Payment Policy No. Re- .97 Policy: Employees and volunteers are prohibited from receiving any gift, gratuity or payment for services rendered, making any promises on behalf of the facility or engaging in any activity, practice, or act which conflicts with the interests of the facility or its residents. Procedure: 1. At no time will an employee or volunteer accept money, gifts valued over $10.00, jewelry etc, from a resident/patient and/or family. Human Resources should be consulted to determine value. If the resident/patient or family is insistent, the employee/volunteer will suggest that they make a donation to The Washington Home or Hospice of Washington. If the party is still insistent, the matter should be presented to the Director of Social Work who will then contact the patient, resident or family member to reaffirm the Home ' s policy . During an environmental tour of Unit 2B on February 29, 2012 at approximately 9:45 AM in the presence of Employee #31 a television and its accompanying equipment (cable box, remotes and cords) were atop shelving in the resident multipurpose area. The television, approximately 19 inches desktop style, was stored in a clear plastic bag proximal to Employee #29 ' s personal belongings (purse/tote bag) and the equipment was observed wrapped in newspaper behind the employee ' s personal belongings. In response to a query regarding the storage of the items atop the shelving, Employee #31 asked Employee #7 to whom do the items belong too. S/he stated that the items belonged to Employee #29. A face-to-face interview was conducted with Employee #15 on February 29, 2012 at 2:00 PM. S/he stated that the television belonged to Resident # F1 who died on yesterday. His/her relative wanted … | 2015-09-01 |
| 1975 | 1975 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 241 | E | 0 | 1 | KI3J11 | Based on resident observations and staff interviews for four (4) of 50 sampled residents, it was determined that facility staff failed to maintain dignity as evidenced by staff standing while assisting resident with meal for one (1) resident; allowing one (1) resident to sit idle as others dinned; one (1) resident asked by staff if he/she wanted an alcoholic beverage and one (1) resident pulled backwards following dinning. Residents #144, #155, #170 and #195. The findings include: 1. Facility staff failed to promote dignity post dining by pulling Resident #144 backwards from the dining area to social area. On February 20, 2012 at approximately 12:40 PM, Employee #22 was observed pulling Resident #144 backwards from the dining area to the social area. A face-to-face interview was conducted with Employee #4 on February 20, 2012 at approximately 12:41 PM. He/she brought the concern to the attention of Employee #22 and corrected the deficient behavior. The observation was made on February 20, 2012. 2. Facility staff failed to ensure Resident #155 ' s dignity was maintained in two (2) of two (2) dining observations as evidenced by Employee #19 standing while assisting with lunch meal. During dining observations conducted on February 21, 2012 at approximately 12:40 PM and March 1, 2012 at approximately 12:45 PM in Resident #155 ' s room on Unit #3A, Employee # 19 was observed assisting Resident #155 with meal consumption. Employee #19 stood proximal to the resident ' s bed and offered spoonfuls of food for the resident to consume. A face-to-face interview was conducted with Employee #10; who observed Employee #19 standing while assisting resident with meal, on March 1, 2012 at approximately 12:45 PM. He/she acknowledged at the time of observation that the employee should have sat down while assisting the resident with lunch meal. 3. Facility staff failed to maintain the resident ' s dignity by asking the resident did he/she wanted an alcoholic beverage. On February 21, 2012 at 12:32 PM during a lunch meal dining observ… | 2015-09-01 |
| 1976 | 1976 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 253 | E | 0 | 1 | KI3J11 | Based on observations during the environmental tours on February 21, 2012 at various times, February 24, 2012 between 9:30 AM and 1:30 PM, and February 29, 2012 from 9:15 AM to12:30 PM, it was determined the facility failed to maintain a sanitary and orderly and comfortable environment as evidence by soiled: carpet in two (2) of 15 hallways observed, carpet in one (1) of one (1) sitting area on Unit 3A; merry walkers in six (6) of six (6) observed; baseboard surfaces in three (3) of 12 observations; Interior and exterior louver surfaces of exhaust vents were soiled in three (3) of 10 observed; surfaces in electrical closets on five (5) of five (5) units; ceiling tile surfaces were soiled in one (1) of two (2) observed. Marred/scarred: surfaces in the pantry in one (1) of five (5) observed; counter top edges at the nursing stations in five (5) of five (5) nursing units observed and entrance doors, door jamb and closet door surfaces were marred and scarred on the frontal surfaces in eight (8) of 20 observed. Damaged: tile in one (1) of three (3) shower rooms observed on Unit 3A; wallpaper was peeled/separated in four (4) of 15 hallways observed; a hole in the wall in the sitting area on one (1) of one (1) observed, a splintered countertop on Unit 1 in one (1) of one (1) countertop observed; a torn white sofa and soiled covering on sofa in one (1) of one (1) white sofa observed; window screens were observed to be damaged and separated from frames in one (1) of four (4) observed and the baseboard was missing in one (1) of one (1) observed. Clutter was observed in two (2) of 30 resident rooms; book shelves were observed with items improperly stored on them in two (2) of two (2) observed and nails were observed sticking out of the wall and the baseboard was detached from the wall in one (1) of 30 resident rooms observed. The findings include: Soiled: 1. Soiled carpet was observed on hallway #1 on Unit 2B, and on hallway #3B in two (2) of 15 hallways observed; Soiled carpet was observed on Unit 3A in the sitting area (n… | 2015-09-01 |
| 1977 | 1977 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 272 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review resident and staff interview for one (1) of 50 sampled residents, it was determined that facility staff failed to accurately code the annual and quarterly Minimum Data Set (MDS) for [MEDICAL CONDITION] and [MEDICAL CONDITION] for Resident #175. The findings include: A during a face-to-face interview with Resident #175 he/she stated, Staff sometimes place my tray down (on the over-the-bed table) and doesn ' t open the items. I can ' t see to open my tray because I am blind in my left eye. A review of the follow up Ophthalmology Consult dated June 29, 2011 revealed, Findings: [MEDICAL CONDITION] OS (left eye), Blind OS .Recommendations: See pt (patient) in 6 months. Stop drops. A review of the annual Minimum Data Set (MDS) completed on August 30, 2011 Resident #175 was coded in Section B1000 (Vision) as his/her vision being moderately impaired. Under Section B1200 (Corrective Lens) the resident was coded as not using corrective lenses. In Section I (Active Diagnoses) the resident was not coded as having visual impairment. The quarterly MDS completed on November 15, 2011 Resident #175 was coded in Section B1000 (Vision) as his/her vision being highly impaired. Under Section B1200 (Corrective Lens) the resident was coded as not using corrective lenses. In Section I (Active Diagnoses) the resident was not coded as having visual impairment. There was no evidence that facility staff accurately coded Resident #175 for the [DIAGNOSES REDACTED]. A face-to-face interview was conducted with Employee #10 on February 28, 2012 at 3:40 PM. He/she acknowledged that the MDS was not coded to reflect the Residents [DIAGNOSES REDACTED]. The record was reviewed on February 28, 2012. | 2015-09-01 |
| 1978 | 1978 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 279 | E | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews for six (6) of 50 sampled residents, it was determined that facility staff failed to initiate care plans with goals and objectives to address: one (1) resident with a positive Level Two Screen; approaches required to ensure safe oral intake of pleasure meals for one (1) resident with dysphagia; for refusal of medications and activities for one (1) resident; for one (1) resident with contractures; one (1) resident with urinary incontinence; and for one (1) resident with allergies [REDACTED].#107, #175, #178, #287 and #337. The findings include: 1. Facility staff failed to develop a care plan with measureable goals and objectives for Resident #2 who has a positive screen for Mental [MEDICAL CONDITION]. A review of the medical record for Resident #2 identifies that the resident was admitted to the facility in March 25, 1968. Review of the PASSAR (Pre-Admissions Screen/Resident Review for Mental Illness and/or Mental [MEDICAL CONDITION]) Screen dated January 20, 2008, identified the resident as positive for Mental [MEDICAL CONDITION]. Review of the quarterly Minimum Data Set with an ARD (Assessment Reference Date) of November 16, 2011 identifies: Section I : [DIAGNOSES REDACTED]. Review of the Social Service's Notes reviewed that the resident's care conference was conducted on December 1, 2011. Relative attended via telephone. Review of the care plans last updated December 1, 2011 lacked evidence of a care plan with appropriate goals and approach to address and resident with a positive screen for Mental [MEDICAL CONDITION]. A face-to-face interview was conducted with the Employee #4 on February 24, 2012 at 5:10 PM. After a review of the care plans, he/she acknowledged the findings. The record was reviewed on February 24, 2012. 2. A review of the clinical record for Resident #107 lacked evidence of problem identification, goals and approaches required to ensure safe oral intake of pleasure meals … | 2015-09-01 |
| 1979 | 1979 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 280 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for two (2) of 50 sampled residents, it was determined that facility staff failed to amend the nutrition care plan for one (1) resident to address the resident ' s current nutritional status and to update one (1) resident ' s care plan to include a [DIAGNOSES REDACTED].# 107 and #175. The findings include: 1. A review of the comprehensive care plan for Resident #107 updated December 6, 2011 revealed facility staff failed to update the nutrition care plan to include the resident ' s current nutritional status. A review of the physician ' s progress notes dated January 20, 2012 revealed the resident ' s [DIAGNOSES REDACTED]. physician's order [REDACTED]. The care plan included the following: problem: alteration in nutrition - needs tube feeding to meet daily needs. The care plan lacked evidence of an update to include the pleasure feeding implemented as of January 25, 2012. The record was reviewed March 1, 2012. 2. Facility staff failed to update the vision care plan to include Resident #175 [DIAGNOSES REDACTED]. A during a face-to-face interview with Resident #175 he/she stated, Staff sometimes place my tray down (on the over-the-bed table) and doesn ' t open the items. I can ' t see to open my tray because I am blind in my left eye. A review of the follow up Ophthalmology Consult dated June 29, 2011 revealed, Findings [MEDICAL CONDITION] OS (left eye), Blind OS .Recommendations: See pt (patient) in 6 months. Stop drops. A review of the annual Minimum Data Set (MDS) completed on August 30, 2011 Resident #175 was coded in Section B1000 Vision as his/her vision being moderately impaired. The quarterly MDS completed on November 15, 2011 Resident #175 was coded in Section B1000 (Vision) as his/her vision being highly impaired. The Visual Function care plan last reviewed November 22, 2011 list, Problem: Visual deficits related to [MEDICAL CONDITION]. There was no evidence that the care plan for vision was … | 2015-09-01 |
| 1980 | 1980 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 309 | G | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview for one (1) of 50 sampled residents, it was determined that facility staff failed to follow physician's order [REDACTED]. Resident #353. The findings include: Facility staff failed to follow physician's order [REDACTED].#353 who was subsequently hospitalized approximately one week post admission, with an acute exacerbation of [MEDICAL CONDITION]. A review of the clinical record for Resident #353 revealed the [AGE] year old was admitted on [DATE] for physical rehabilitation with [DIAGNOSES REDACTED]. The resident was admitted with an indwelling urinary catheter to manage a history of [MEDICAL CONDITION] and a peripherally inserted central catheter (PICC) of the right upper arm. The resident ' s medication regimen included intravenous antibiotic therapy administered every six (6) hours for urosepsis. Interdisciplinary notes documented by the medical team included, but was not limited to the following: February 10, 2012 (no time indicated)- admission physical examination; Extremities: 3+ [MEDICAL CONDITION]; lungs clear with bilateral congestion and good air flow. February 14, 2012 at 10:00 AM; Patient ' s (responsible party named) concerned that patient is more lethargic and short of breath than usual .Assessment - hypoxic, recent urosepsis, dementia .Plan - [MEDICATION NAME] (diuretic) 40 mg po (by mouth) for one dose, oxygen at 2 liters via nasal cannula with pulse oximetry (P02) assessments every shift, maintain P02 at 94%. February 15, 2012 (no time indicated)-chief complaint: nurse reports patient with [MEDICAL CONDITION] generalized . examination - bilateral lower extremity taut [MEDICAL CONDITION] 2+, right upper extremity [MEDICAL CONDITION] 1+, mild dyspnea (shortness of breath) and tachypnea (rapid breathing); Treatment plan - start low dose [MEDICATION NAME] 10 mg po daily .CXR (chest x-ray), respiratory consult for [MEDICAL CONDITION] toileting, bilateral lower extremity compression stockings . F… | 2015-09-01 |
| 1981 | 1981 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 312 | D | 0 | 1 | KI3J11 | Based on observation and interviews for one (1) of 50 sampled residents, it was determined that facility staff failed to ensure incontinence care was provided consistent with one (1) resident ' s needs. Resident #107. The findings include: On February 28, 2012 at approximately 3:40 PM a face-to-face interview was conducted with the responsible party for Resident #107. The responsible party conveyed that s/he had informed the staff that the resident was in need of incontinence care but hours passed and incontinent care had not been provided to the resident. In response to concerns regarding the provision of care verbalized by Resident #107 ' s responsible party (RP), an observation was conducted. On February 28, 2012 at approximately 3:50 PM, moments after the RP verbalized the concerns to the survey team, facility staff were observed transporting the resident from a common area on the unit to his/her room via wheelchair. Staff transferred the resident via mechanical lift and proceeded to provide incontinent care. The staff removed the resident ' s incontinent brief and it was observed to be soggy and thoroughly saturated with urine. An interview was conducted with the staff who performed the incontinence care at the time of the observation. In response to a query regarding the last time the resident received incontinence care, they responded that they were unaware because they recently arrived to duty for the evening shift. Facility staff failed to provide incontinence care consistent with the resident ' s needs as evidenced by the removal of a soggy and thoroughly saturated incontinent brief. The observation was made on February 28, 2012. | 2015-09-01 |
| 1982 | 1982 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 314 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview for one (1) of 50 sampled residents, it was determined that facility staff failed to ensure that one (1) resident received necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. Resident #45 The findings include: 1. Facility staff failed to ensure that Resident #45 received necessary treatment and services, promoted healing, prevented infection and prevented new sores from developing. The quarterly Minimum Data Set (MDS) completed November 15, 2011; under Section I (Active Diagnoses) included the following Diagnoses: [REDACTED]. The Braden Scale (for predicting pressure sore risk) completed November 8, 2011equaled a score of 18 (low risk). The Laboratory Report dated January 11, 2012 revealed that the resident ' s Red Blood Count was 3.31-low (range, 4.30-5.70); Hemoglobin was 10.6-low (range, 11.6-15.6); Hematocrit was 30.4-low (range, 34.0-46.0) physician's order [REDACTED].>The physician's order [REDACTED]. The physician's order [REDACTED]. The physician's order [REDACTED]. The physician's order [REDACTED]. The physician's order [REDACTED]. The physician's order [REDACTED]. Cleanse left buttock pressure ulcer with normal saline, pat dry, apply Santyl to wound base, cover with dry dressing twice daily for 30 days and reassess. The physician's order [REDACTED]. Cleanse pressure ulcer to coccyx with normal saline, pat dry, apply Santyl and [MEDICATION NAME] powder to wound, twice daily until healed. The physician's order [REDACTED]. Medication Administration Record On November 2, 2011 the Medication Administration Record [REDACTED]. Nurse ' s initials were placed in the designated box on November 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, and 14 indicating adherence to the aforementioned entry. On November 17, 2011 the MAR indicated [REDACTED]. Nurse ' s initials were placed in the designated box on November 17, 18, 19, 20, 21, 22, 2… | 2015-09-01 |
| 1983 | 1983 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 315 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview for one (1) of 50 sampled residents, it was determined that facility staff failed to provide services to improve/prevent a decline in bladder function for Resident #287. The findings include: A face-to-face interview was conducted with Resident #287 at 12 noon on March 1, 2012. Resident informed this investigator that he/she has problems with what he/she described as dribbling and wears what he/she called pull-ups. In response to a query whether he/she participates in any form of bladder training, he/she responded no. A review of the clinical record revealed that the resident was admitted to the facility on [DATE]. A review of the admission MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of October 14, 2011 revealed that the resident was coded with a one (1) which indicated that the resident was occasionally incontinent under Section H 0300 (Urinary Continence). However, the quarterly assessment dated [DATE] revealed that the resident was coded with a three (3) indicating that the resident was always incontinent in H0300. Resident #287 had not been evaluated for and/or involved in a bladder training program as evidenced by the coding of the admission and quarterly MDS ' dated October 14, 2011 and December 20, 2011 respectively. A no response was coded in Section H-0200, (Urinary Continence), indicative that a toileting plan had not been attempted. There was no evidence that facility staff provided appropriate treatment and services to improve and/or prevent a decline in bladder function for Resident #287. A face-to-face interview was conducted with Employee #10 on March 1, 2012 at approximately 12:15 PM. In response to a query whether the resident receives bladder training, he/she stated no. The record was reviewed on March 1, 2012. | 2015-09-01 |
| 1984 | 1984 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 323 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on record review and staff interview for three (3) of 50 sampled residents, it was determined that facility staff failed to ensure application and functionality of a posey senor alarm for one (1) resident; failed to properly supervise one (1) resident during transfer from the wheel chair to the bed resulting in an injury, and failed to properly assess the use of a posey sensor monitor for one (1) resident. Residents #107, #137, and #237. The findings include: 1. Facility staff failed to ensure the application and functionality of a posey sensor pad alarm (bed alarm) to Resident #107 ' s bed. physician's order [REDACTED]. An observation of Resident #107 on February 28, 2012 at 4:00 PM revealed the resident was lying in bed after being assisted to bed by facility staff. A cord was observed dangling from the bed onto the floor. Electrical appearing wires of various colors were protruding from the distal end of the cord. The staff assisting the resident stated that the cord was a part of the resident ' s bed alarm, in response to my query regarding the purpose and origin of the wires. They concluded that the cord was not functioning as intended and that an adaptor piece was detached. A review of the treatment administration record (TAR) for February 2012 revealed that staff initialed in the box for the day shift on February 28, 2012 indicating that the bed alarm was in place. A face -to-face interview was conducted with Employee #10 on February 28, 2012 at 4:45 PM. S/he acknowledged the findings. 2. Facility staff failed to properly assess the posey sensor monitor for Resident #137 who was discovered on the fall mat inside of his/her room. A review of the unusual incident report dated February 22, 2012 revealed that Resident #137 sustained a fall without injury on February 22, 2012 at 7:45 AM. The report read: Resident was observed lying on (his/her) floor mat bedside bed. Through face-to-face interview with Employee #20 on February 22, … | 2015-09-01 |
| 1985 | 1985 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 328 | D | 0 | 1 | KI3J11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview for one (1) of 50 sampled residents, it was determined that facility staff failed to comprehensively assess and act on physician's order [REDACTED].#353. The findings include: The respiratory therapist failed to comprehensively assess the respiratory status of Resident #353 who exhibited respiratory difficulty and fluid retention, was subsequently diagnosed with [REDACTED]. A review of the clinical record for Resident #353 revealed the [AGE] year old was admitted on [DATE] for physical rehabilitation with [DIAGNOSES REDACTED]. The physician ordered a chest x-ray on February 15, 2012. The study was performed and results provided on February 16, 2012. The findings of the Chest x-ray cardiomegaly (enlarged heart) with [MEDICAL CONDITION] vascular congestion and bilateral pleural effusions. The physician wrote an order for [REDACTED]. A physician's order [REDACTED]. Approximately 10 hours lapsed before the initial neb treatment was administered at 9:00 PM on February 17, 2012. EMS (emergency medical services) was activated and the resident was transported to the hospital approximately 5 hours later at 1:50 AM on February 18, 2012. The request for the respiratory consult was acted on after 2 days, on February 17, 2012 at 10:38 AM. The consultation form remained blank and the therapist completed a Respiratory Therapy Recommendations and Order Request form that read: patient cannot tolerate any [MEDICAL CONDITION] toileting at this time. Incentive spirometer recommendation for 10 days as tolerated by patient. Duo-Neb treatment every 4 hours ordered as well .to start treatment as soon as medication is available. A Respiratory Treatment Note, February 17, 2012 10:55 AM read: IS (incentive spirometer) therapy for [MEDICAL CONDITION] toileting; lung sounds pre-treatment decreased and post-treatment slight improvement. SPO2 88-95%. Patient instructed and encouraged with use of IS at this time. Patient was unable… | 2015-09-01 |
| 1986 | 1986 | THE WASHINGTON HOME | 95005 | 3720 UPTON STREET NW | WASHINGTON | DC | 20016 | 2012-03-06 | 371 | D | 0 | 1 | KI3J11 | Based on a tour of the kitchen on February 24, 2012 at approximately 5:00 PM, it was determined that staff failed to store, prepare and/or distribute foods under sanitary conditions as evidenced by five (5) of 18 damaged pellet plates and one (1) of three (3) hand washing sinks was non-operational. The findings include: 1. Five (5) of 18 burgundy pellet plates were damaged. 2. One (1) of three (3) hand washing sinks was non-operational. These findings were made in the presence of Employee #34 at the time of the observation. | 2015-09-01 |
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CREATE TABLE [cms_DC] ( [facility_name] TEXT, [facility_id] INTEGER, [address] TEXT, [city] TEXT, [state] TEXT, [zip] INTEGER, [inspection_date] TEXT, [deficiency_tag] INTEGER, [scope_severity] TEXT, [complaint] INTEGER, [standard] INTEGER, [eventid] TEXT, [inspection_text] TEXT, [filedate] TEXT );