Bridgepoint Subacute and Rehab Capitol Hill

Inspectors wroteBased on record review and staff interviews, for one (1) of 53 sampled residents, facility staff failed to order a wound consult and treatment for a resident who was observed with blisters on his right buttock. Subsequently, five (5) days later, the resident was observed with a Stage 3 pressure ulcer to his right buttock. Resident #38.

Inspectors wroteBased on record review and staff interviews, for one (1) of 53 sampled residents, facility staff failed to complete a thorough investigation for a facility-reported incident (FRI) that alleged a facility staff removed a 10-tablet blister pack of Resident #38's narcotic pain medication.

Inspectors wroteBased on record review and staff interview, for one (1) of 53 sampled residents, facility staff failed to revise and update Resident #112's care plan with goals and interventions to address a left medial lower leg and right knee abrasions.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, record review, and staff and family interview, for one (1) of 53 sampled residents, the facility failed to ensure that: (1) Resident 43's gown and linen were dry and free from stains, and incontinent care was provided in a timely manner. And (2) Resident #43 was turned and repositioned in a timely manner. (Resident #43)

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review, staff interview, and family interview, the facility's staff failed to ensure that a resident with a tracheostomy was accompanied by nursing staff during a podiatry appointment for one of the 53 sampled residents. (Resident #43) Resident #43 was admitted to the facility on [DATE] with multiple diagnoses, including Aphasia, Chronic Respiratory Failure, Tracheostomy, and Muscle Weakness. A physician order with a re-order date of 01/31/26 instructed, On Trach collar: FI02:28%, Trach Type: [NAME], Trach Size: XL 7 every shift. Trach and suction care by a respiratory therapist and a nurse every shift. A quarterly Minimum Data Set assessment dated [DATE] showed that the resident did not have a Brief Interview for Mental Status summary score, indicating that the assessment was not conducted. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on record review, staff interview, and family interview, the facility failed to ensure Employee #22 (CNA) did not remove a soiled sacral dressing and replace it with a clean gauze for one of 53 sampled residents. (Resident #43)Resident#43 was admitted to the facility on [DATE]. The resident has a history of Cerebral Infarction, Muscle Weakness, and Stage 3 and Stage 4 Pressure Ulcers. A care plan with a review date of 12/18/25, documented in part, Focus [Resident #43 has pressure ulcers related to disease process (Chronic respiratory failure, chronic kidney disease, diabetes.immobility. Intervention- administer treatments as ordered and monitor for effectiveness [LPN, RN, or NP]. [...]

Inspectors wroteBased on observation, record review, and staff interview, for one (1) of 53 sampled residents, facility staff failed to ensure proper storage of Resident #43's medication.

Inspectors wrote2. A policy titled, Smoking Policy with a review date of 12/2024 instructed in part, To protect the health, safety, and comfort of our residents, visitors, medical staff and employees . Bridge Point is a smoke free facility. Smoking may not occur with the facility. This policy is applicable to all employees, staff, visitors, and residents, both smokers and non-smokers. The information in this policy will be reviewed with all staff during orientation and on an annual basis .Residents receive information regarding policy during the admission process .Residents and visitor compliance with the policy is a shared responsibility of all Bridge Point employees and staff .The nursing facility acts to minimize the smoke (sp) to the greatest extent possible. The nursing facility will provide smoking jackets for resident use for safety . 2a. [...]

Inspectors wroteBased on observation, record reviews and staff interviews for one (1) of 39 sampled residents, facility staff failed to consistently assess and document changes in the skin of Resident #47 who developed an in-house, acquired pressure injury/ulcer that was first identified at an advanced stage (Stage 3). (Resident #47) These failures resulted in actual harm to Resident #47.

Inspectors wroteBased on record reviews and staff interviews, facility staff failed to ensure that staff members were educated on the resident's rights and the facility's responsibilities to properly care for its residents, as set forth at §483.10, respectively.

Inspectors wroteBased on record reviews and staff interviews, facility staff failed to provide training that outlined and informed staff of the elements and goals of the facility's QAPI program.

Inspectors wroteBased on record reviews and staff interviews, facility staff failed to provide a training program or another practical manner to effectively communicate the standards, policies, and procedures of the compliance and ethics program to its entire staff.

Inspectors wroteBased on record reviews and staff interviews, facility staff failed to show documented evidence of its Required In-Service Training for Nurse Aides.

Inspectors wroteBased on record reviews and staff interviews, facility staff failed to show documented evidence of an effective training program for all staff, which includes, at a minimum, training on behavioral health care and services for its residents.

Inspectors wroteBased on record review and staff interview, five (5) of 49 residents sampled, facility staff failed to have documented evidence that they provided information to the residents and/or their representatives (RP) regarding their right to formulate or refuse an advanced directive. Residents #87, #56, #91, #74, and #73.

Inspectors wrote5. Resident #91 was admitted to the facility on [DATE] with multiple diagnoses that included: Interstitial Pulmonary Disease, Type 2 Diabetes Mellitus and Chronic Respiratory Failure. Review of the resident's medical record revealed the following: An admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 13, indicating intact cognitive response. Physician's orders dated 02/10/15 directed, Established [central] line - Change dressing Q (every) 7 days, every night shift every Monday for IV-line care; Change dressing as needed if not intact or soiled as needed for IV care; Observe insertion site every shift for redness, warmth, swelling, drainage, coldness or irritation, every shift for IV care. [...]

Inspectors wroteBased on observation, record review and resident and staff interview, the Interdisciplinary Team (IDT) failed ensure a resident was safe to self-administer an Albuterol inhaler for one (1) of 1 sampled resident who self-administer medicine. (Resident #46).

Inspectors wroteBased on record reviews and staff and family interviews, the facility failed to have documented evidence that verbal abuse of resident did not occur after receiving an allegation of staff-to-resident verbal abuse for one (1) of 1 sampled residents. (Resident #158)

Inspectors wroteBased on observations, record reviews and staff interviews for one (1) of 49 sampled residents, facility staff failed to provide documented evidence that one resident's bedrails were not being used as a restraint for a non-ambulatory, cognitively impaired resident who required extensive assistance with bed mobility and transfers. Resident #308.

Inspectors wroteBased on record reviews and staff interviews for two (2) of 49 sampled residents, facility staff failed to report an incident of alleged staff-to-resident verbal abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures.

Inspectors wroteBased on record review and staff interviews, for two (2) of 49 residents sampled, facility staff failed to have documented evidence that they conducted thorough investigations for one resident's missing cellphone and one resident's allegation of staff-to resident verbal abuse. Residents #87 and #81.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of 49 sampled residents, the facility staff failed to review the comprehensive person-centered care plan as required. (Resident #38)

Inspectors wroteBased on observations, record reviews and staff interviews, for two (2) of 49 residents sampled, facility staff failed to ensure that residents, who are unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene. Residents #87, and #86.

Inspectors wroteBased on observation, record review and staff interview, for two (2) of 49 sampled resident's the facility's staff failed to follow: (1) Professional Standards of Practice when preparing to administer a subcutaneous injection as evidenced by Employee #16 prepared who a Heparin [anticoagulant] injection using an intramuscular (IM) gauge and length needle instead of a subcutaneous (SQ) gauge and length needle. It should be noted that the surveyor intervened before Employee #16 administered Heparin with the IM gauge and length needle. And (2) failure to follow physician's orders and care plan for turning and repositioning Resident #74 every two (2) hours.

Inspectors wroteBased on observations, record reviews and staff interviews, the facility staff failed to provide a resident with water flushes via Percutaneous Endoscopic Gastrostomy (PEG) tube as prescribed for one (1) of 49 sampled residents. (Resident #38)

Inspectors wroteBased on observations, record reviews and staff interviews, for two (2) of 49 residents sampled, facility staff failed to ensure that the residents received care and services, consistent with professional standards of practice, for their central intravenous (IV) lines. Residents' #91 and #53.

Inspectors wroteBased on record review and staff interviews, for one (1) of 49 residents sampled, facility staff failed to ensure that Resident #53's attending physician evaluated his total program of care as evidenced by failing to have documented evidence that the physician reviewed the pharmacist recommendations for four (4) months.

Inspectors wroteBased on observations, record reviews and staff interviews, for two (2) of 49 residents, sampled, facility staff failed to demonstrate appropriate competencies and skills sets to provide safe nursing services. Residents #73 and #209.

Inspectors wroteBased on observation, record review, and staff interview, the facility's staff failed to ensure a resident's medication recently received from pharmacy was available for administration for one (1) of 49 sampled residents. (Resident #75)

Inspectors wroteBased on record review and staff interviews, for one (1) of 49 residents sampled, facility staff failed to have documented evidence that the attending physician reviewed and acted upon identified irregularities noted by the pharmacist. Resident #53.

Inspectors wroteBased on observations and staff interview, facility staff failed to ensure that the medication error rate was 5% or less. Subsequently, the facility had a 16% medication error rate.

Inspectors wroteBased on observations, record reviews and staff interviews, facility staff failed to ensure safe and secure storage of residents' medications as evidenced by storing: three (3) opened and undated vials of insulin for three residents in the medication refrigerator, two, opened, expired insulin vials for two (2) residents in the medication refrigerator, and by failing to remove one Resident's insulin pen from the medication refrigerator after the Resident was discharged from the facility. Residents #9, # 64, #77, #209, and #259.

Inspectors wroteBased on observation, record reviews, and staff interviews, the facility staff failed to ensure that food was prepared in a form designed to meet the individual needs for one (1) of six (6) sampled residents who was prescribed a mechanically altered diet. Subsequently, Resident #38 was served roast beef that was not mechanically altered to bite size as prescribed. (Resident #38)

Inspectors wroteBased on observations and interview, during a tour of the kitchen on April 13, 2025, at approximately 6:30 AM, facility staff failed to store and distribute food under sanitary condition as evidenced by one (1) of one (1) open bag of shredded carrots that was stored in the walk-in freezer undated, two (2) of five (5) torn air/strip curtains in one (1) of one (1) walk-in refrigerator/freezer unit, six (6) of six (6) ceiling lights above the three-compartment sink that were soiled with dust, one (1) of two (2) open eyewash solution bottle that was stored by the tray line for use, one (1) of two (2) garbage disposals that was inoperative , two (2) of two steamers with an 'out of service since May 8, 2023' sign, one (1) of two food warmers that has been inoperative since June 1, 2023. [...]

Inspectors wroteBased on a review of the facility's records and a staff interview, the facility failed to comply with the State Regulation (22B DCMR sect. 3211.5) for daily staffing ratios, as evidenced by not providing the minimum daily average of four and one tenth (4.1) hours of direct nursing care per resident per day, with at least six tenths (0.6) hours being provided by a registered nurse for seven (7) of 35 sampled days.

Inspectors wroteBased on record review and staff interview for one (1) of 49 residents sampled, facility staff failed to have accurate documentation in Resident #209's medical record.

Inspectors wroteBased on observation and staff interview, for one (1) of two (2) sampled residents that were administered insulin, the facility's staff failed to follow acceptable Infection Control practices. As a result Employee #47 (RN) failed to perform hand hygiene after administering insulin. (Resident #38) Resident #38 was admitted on [DATE] with multiple diagnoses including Type 2 Diabetes Mellitus. A policy titled, Subcutaneous Injections with a review dated of 05/24/24 instructed on part, Put on gloves .Select appropriate injection site . slowly inject medications .with drawn needle quickly .discard equipment .remove gloves .perform hand antiseptic [hand hygiene] . A physician order dated 02/12/25 instructed, Humalog 100 UNIT/ML (Insulin Lispro) Inject as per sliding scale: if 0 - 150 = 2unit; 151 - 200 = 4unit; 201 - 250 = 6unit; 251 - 300 = 8unit; 301 - 350 = 10unit; [...]

Inspectors wroteBased on observations, and interview, facility staff failed to ensure that the environment remains free of pest as evidenced by three (3) of three (3) mouse traps that were observed around the cook line, one (1) of one (1)mouse trap and mouse droppings in the dishwashing machine room, and flying pest in the three-compartment sink area.

Inspectors wroteBased on record review and staff interviews, for two (2) of 42 sampled residents, facility staff failed to implement its policy as evidenced by: 1) not having documented evidence they conducted a background check or that an employee received abuse education and 2) not removing the alleged perpetrator (facility staff) from the facility to protect the alleged victim (resident) from further abuse pending an investigation. Residents' #70 and #31.

Inspectors wroteBased on record review and staff interview for three (3) out of 42 sampled residents, the facility staff failed to provide written information to the resident or resident representative that stated the duration of the State Agency's bed-hold policy before the facility transferred the Resident to the hospital. Residents' #2, #310, and #34.

Inspectors wroteBased on record review, and staff interview for one (1) of 42 sampled residents, the facility staff failed to develop a resident's person-centered comprehensive care plan with goals and approaches for the use of an indwelling Foley catheter. Resident #54.

Inspectors wroteBased on record review, and staff interviews, for one (1) of 42 sampled residents, the facility's staff failed to ensure Resident #362 was provided appropriate care to prevent the resident's suprapubic catheter from becoming dislodged during care. Resident #362.

Inspectors wroteBased on record review, resident and staff interview, for one (1) of 42 sampled residents, Employee #5 (Licensed Practical Nurse/LPN), failed to ensure that Resident #46 received effective pain management in accordance with the physician's orders and the comprehensive care plan.

Inspectors wroteBased on one (1) of five (5) observations and staff interview, facility staff failed to demonstrate competency to provide appropriate nursing services to assure resident safety.

Inspectors wroteBased on one (1) of five (5) observations, record review and staff interviews, facility staff failed to ensure that the system to account for the reconciliation of controlled medications was followed.

Inspectors wroteBased on observations and staff interview, the facility failed to serve cold food (pineapples and pears) at or below 41 degrees Fahrenheit for two (2) of 2 opportunities.

Inspectors wroteBased on record review and staff interview, for one (1) of 42 sampled residents, facility staff failed to operate and provide services in compliance with applicable State regulations regarding professionals providing services in the facility. Resident #70.

Inspectors wroteBased on record reviews and staff interviews, for one of eleven (11) sampled residents, facility staff failed to report the results of its investigation for an incident involving resident-to-resident verbal abuse to the State agency within five (5) working days of the incident. Residents #3 and #5.

Inspectors wroteBased on record review and staff and resident interviews for (1) of eleven sampled residents, facility staff failed to update Resident #3's care plan interventions after the Resident had another verbal altercation with a second resident (Resident #5).

Inspectors wroteBased on observation, record review and staff interviews of (1) of eleven sampled residents, facility staff sat at the nurse's station and failed to respond to a resident's room while the ventilator alarmed continuously to alert staff of a ventilator emergency when the HME (heat moisture exchange) tubing had dislodged from the resident's tracheostomy collar for longer than one minute. (Resident #8).

Inspectors wroteBased on record reviews and staff interview, for four (4) of nine (9) sampled residents, facility staff failed to provide the residents, or their representatives, with written information that specified the duration of the state bed-hold policy before transfer to the hospital. Residents' #2, #3, #5 and #9.

Inspectors wroteBased on record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to immediately (within 2 hours) report an allegation of employee-to-resident physical abuse to the State Agency. Resident #7.

Inspectors wroteBased on record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to have documented evidence that an allegation of employee abuse was thoroughly investigated at the time when staff first had knowledge of the allegation. Resident #7.

Inspectors wroteBased on record review and staff interview, for one (1) on nine (9) sampled residents, facility staff failed to accurately code Resident #5's resident's admission Minimum Data Set (MDS) assessment for a deep tissue injury on the sacrum.

Inspectors wroteBased on record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to revise one (1) resident's care plan to include use of an arm sling for immobilization for a right shoulder fracture. Resident #3.

Inspectors wroteBased on record review and staff interview, for one (1) of nine (9) sampled residents, facility staff failed to ensure that a resident who was unable to carry out activities of daily living received the necessary care and services to maintain grooming and personal hygiene. Resident #6.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of nine sampled residents, facility staff failed to ensure one (1) resident received appropriate care and services to prevent potential complications (contamination and infection) of enteral feedings. Resident #3.

Inspectors wroteBased on observations, record review, staff, and resident interviews, for one (1) of 53 sampled residents, facility staff failed to ensure that Resident #266 was free from mental abuse and rough handling/physical abuse by a licensed practical nurse employed by the facility. These failures resulted in psychosocial harm to Resident #266.

Inspectors wroteBased on record review and staff interview, facility staff failed to updated their COVID-19 policies and procedures to include contingency plans for staff who are not fully vaccinated. The resident census on the first day of survey was 110.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement its Abuse Investigation and Reporting policy by not investigating the following incidents: (1) a resident who had an unwitnessed fall with injury resulting in the resident being transferred to the hospital for evaluation; (2) a resident who sustained a minor injury after a portable fan fell on the resident; (3) a resident who had a witnessed fall with a minor injury; (4) a resident who had an unwitnessed fall without injury; (5) a resident whose gastrostomy tube was dislodged; and (6) a residents whose midlines were dislodged. Residents' #30, #32, #79, #263, #105 and #207.

Inspectors wroteBased on record review and staff interview for one (1) of 53 sampled residents, facility staff failed to have an admissions policy in place; and failed to ensure residents and or their responsible party reviewed and signed an admission contract, informing them of the facility's approach to finances, residents' rights, care, treatment and services, and advance directives. Resident #95.

Inspectors wroteBased on observations, record reviews, and staff interviews, for six (6) of 53 sampled residents, the facility's staff failed to develop a care plan with goals and approaches to address: the use of a portable fan; monitoring a resident for signs and symptoms of Depression; and restorative nursing for a residents; Dementia care for a resident; the use of antibotics for a resident and to implement the interventions for a resident at risk for falls. (Residents' #32, #96, #79, #2, #262, and #263)

Inspectors wroteBased on observations, record reviews and staff interviews, for four (4) of 53 sampled residents, facility staff failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan as evidenced by failure to: (1) provide activities of daily living (ADL) in a manner that prevented a Resident #29's midline (intravenous line) from being dislodged; (2) administer Vancomycin (antibiotic) liquid to Resident #55 by the incorrect route; (3) administer Midodrine (increases blood pressure) to Resident #81 in accordance with the physician's order; and (4) obtain orders to treat Resident #92's noted rash on the perineum and legs.

Inspectors wroteBased on observation and interview, for two (2) of 53 sampled residents, the facility's staff failed to maintain Standards of Infection Control Practices when providing tracheostomy care for Resident #103 and when suctioning Resident #81.

Inspectors wroteBased on record review and staff interview, for three (3) of 53 sampled residents, facility staff failed to ensure that there was documentation in the resident's medical record of the information/education provided regarding the benefits and risks of immunization, the administration or the refusal of or medical contraindications to the vaccine(s). Residents' #6, #262 and #263.

Inspectors wroteBased on record review and staff interview, facility staff failed to ensure that one (1) staff member was in compliance with receiving the COVID-19 vaccination series. The resident census on the first day of survey was 110.

Inspectors wroteBased on record review and staff interview, the facility's staff failed to provide Advance Directive information to incapacitated resident or their representatives; and to offer a resident or their representative the opportunity to formulate an Advance Directive for three (3) of 53 sampled residents (Residents' #30, #96 and #26).

Inspectors wroteBased on record review and staff and resident's representative interview, the facility's staff failed to notify a resident's representative of a resident's change in status (self-decannulation), which resulted in the resident being transferred to the emergency room for re-insertion of a tracheostomy tube for one (1) of 53 sampled residents (Resident #102).

Inspectors wroteBased on record review and staff interviews, for one (1) of 53 sampled residents, facility staff failed to provide documented evidence that a baseline care plan was provided to a resident or his representative within 48 hours of readmission into the facility.

Inspectors wroteBased on record review and staff interview for one (1) of 53 sampled residents, facility staff failed to accurately record the location and status of a wound Resident #261's.

Inspectors wroteBased on record review and staff interview, for two (2) of 53 sampled residents, the facility's staff failed to (1)provide supervison during activities of daily living (ADL) care which resulted in Resident #29's midline (intravenous line) being dislodged and (2) ensure that a space heater was not used to heat Resident #1's room.

Inspectors wroteBased on record review and staff interview, for two (2) of 53 sampled residents, facility's staff failed to address an unusual weight for a resident; and failed to ensure that a resident maintained acceptable parameters of nutritional status, such as usual body weight. Residents' #30 and #63.

Inspectors wroteBased on record review and staff interview for three (3) of 53 sampled residents, facility staff failed to ensure the residents with Midlines (A catheter that is inserted in a peripheral vein and ends near the upper arm use for intravenous therapy) were assess for complications at the insertion site during the therapy and post removal or dislodgement of the catheter. (Residents' #55, #93, and #63.)

Inspectors wroteBased on observation, record review and staff interviews for (1) one of 53 sampled residents, facility staff failed to provide respiratory care that is consistent with professional standards of practice for one resident who was receiving humidified oxygen. Resident #34.

Inspectors wroteBased on record review and staff interview for one (1) out of 53 sampled residents, facility staff failed to provide treatment, services, and develop a plan of care for Resident #2's diagnosis of dementia.

Inspectors wroteBased on observation and staff interviews, facility staff failed to ensure one (1) expired vial of influenza vaccine and one (1) vial of tuberculin Purified Protein Derivative, PPD injection, were discarded and not stored for use in two (2) of three (3) medication refrigerators observed.

Inspectors wroteBased on record review and staff interviw for two (2) of 53 sampled residents, facility staff failed to ensure Resident #78 received the appropriate treatment when he/she complained of pain during urination; and failed to obtain labs in accordance with the physician's order for Resident #81.

Inspectors wroteBased on observation and staff interview, facility staff failed to ensure that survey results were placed in a readily accessible location where residents and visitors wishing to examine them could do so without having to ask staff to see them. The census on the first day of survey was 110.

Inspectors wroteBased on observations and interview, facility staff failed to store foods under sanitary conditions as evidenced by two (2 of six (6) slats in the main freezer that were torn throughout.