Complete Care at Germantown

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect more than 4 of the 53 residents residing in the facility. The facility did not cool food with an approved food cooling method.

Inspectors wroteBased on staff interview and record review, the facility did not ensure protective placement was obtained for 1 resident (R) (R3) of 3 sampled residents. R3 had a court-ordered Guardian and was admitted to the facility on [DATE]. The facility did not petition for protective placement when R3's stay exceeded 60 days.

Inspectors wroteBased on staff interview and record review, the facility did not notify the Ombudsman of hospital transfers for 3 residents (R) (R15, R39, and R4) of 3 residents reviewed for hospitalization. R15 was transferred to the hospital on 9/11/24. The facility did not notify the Ombudsmen of R15's hospital transfer. R39 was transferred to the hospital on [DATE], 12/23/24 and 1/16/25. The facility did not notify the Ombudsmen of R39's hospital transfers. R4 was transferred to the hospital on [DATE]. The facility did not notify the Ombudsmen of R4's hospital transfer.

Inspectors wroteBased on staff interview and record review, the facility did not ensure 1 resident (R) (R46) of 2 sampled residents was screened through the Pre-admission Screen and Resident Review (PASRR) Level II process to determine if nursing home placement was appropriate and if specialized services were required. The facility did not ensure completion of a Level II PASRR Screen for R46 or follow a Qualified Mental Health Professional's (QMHP) request to refile a Level II PASRR Screen if R46 remained in the facility.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the accurate administration of drugs and biologicals for 5 residents (R) (R5, R20, R4, R7, and R9) of 20 sampled residents. On 1/30/25, medications were observed at R5, R20, R4, R7, and R9's bedsides. The residents did not have self-administration of medication assessments, physician orders to self-administer medication, or care plans that indicated they could safely and accurately self-administer medication.

Inspectors wroteBased on staff and resident interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when they did not ensure allegations of abuse and misappropriation were reported to the State Agency (SA) or local law enforcement for 3 residents (R) (R3, R4, and R9) of 11 sampled residents. Director of Nursing (DON)-B was informed of a resident-to-resident altercation between R3 and R4 on 6/17/24 in which R3 sustained a physical injury. The facility did not report the allegation of abuse to the SA or local law enforcement. The facility did not report an allegation of misappropriation of property for R9 to the SA or local law enforcement.

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure allegations of abuse and misappropriation were thoroughly investigated for 3 residents (R) (R3, R4, and R9) of 11 sampled residents. Director of Nursing (DON)-B was informed of a resident-to-resident altercation between R3 and R4 on 6/17/24 in which R3 sustained a physical injury. The facility did not thoroughly investigate the allegation of abuse. R9 reported R9's wallet, debit card, and cash were missing. The facility did not thoroughly investigate the allegation of misappropriation.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an injury of unknown origin and allegation of sexual abuse were reported to the Nursing Home Administrator (NHA), the State Agency (SA) and/or local law enforcement in a timely manner for 2 residents (R) (R1 and R2) of 7 sampled residents. On 4/10/24, the facility discovered R1 had a fracture of unknown origin. Staff did not immediately report the injury of unknown origin to NHA-A which delayed the facility's report to the SA. On 4/8/24, R2 alleged R2 was raped by a male nurse. Staff did not immediately report the allegation of sexual abuse to NHA-A which delayed the facility's report to the SA and local law enforcement.

Inspectors wroteBased on staff interview and record review, the facility did not prevent further potential abuse during an investigation of sexual assault for 1 resident (R) (R2) of 7 sampled residents. R2 accused Licensed Practical Nurse (LPN)-F of sexual abuse on 4/8/24. The facility did not remove LPN-F from resident care pending the results of the investigation.

Inspectors wroteBased on staff and resident interview, and record review, the facility did not ensure scheduled showers were provided for 5 Residents (R) (R212, R22, R30, R38, R47) of 22 sampled residents. R212, R22, R30, R38, and R47 did not consistently receive scheduled showers.

Inspectors wroteBased on resident and staff interview, and record review, the facility did not make a prompt effort to resolve grievances for 3 Residents (R) (R32, R20, and R212) of 5 sampled residents. R32 and R32's Power of Attorney (POA) reported R32's wallet and phone were missing. There was no follow up by the facility. R20's POA filed a grievance related to missing clothing. There was no follow up by the facility. R212 and a family member filed a grievance related to call light wait times and customer service. The grievance was not fully addressed and there was no follow up by the facility.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure 1 Resident (R) (R31) of 1 resident was assessed for the use of bed rails. R31 had bilateral half rails on R31's bed. Staff did not assess R31 for the use of bed rails, and did not obtain informed consent or a physician's order when the bilateral half rails were implemented.

Inspectors wroteBased on staff interview and record review, the facility did not record, thoroughly investigate, and provide follow up or resolution of a grievance for 1 Resident (R) (R2) of 3 residents reviewed. A grievance, dated 10/24/23, was filed on behalf of R2 related to hygiene. The facility did not thoroughly investigate or provide follow-up and resolution for the grievance.

Inspectors wroteBased on staff interview and record review, the facility did not review and revise the care plan for 1 Resident (R) (R1) of 5 sampled residents. R1's plan of care indicated R1 had a passive range of motion (PROM) program; however, R1's care plan was not updated to include an intervention for active assistive range of motion (AAROM) on the right side.

Inspectors wroteBased on staff and provider interview, and record review, the facility did not notify the provider of an elevated blood sugar level for 1 Resident (R9) of 28 residents reviewed. R9 had a documented blood sugar level of 495 mg (milligrams)/dL (deciliter) on 2/25/23. R9's provider was not notified.

Inspectors wroteBased on staff interview and record review, the facility did not record, thoroughly investigate, or provide resolution of a grievance for 1 Resident (R) (R10) of 28 residents reviewed. R10's dentures were reported missing on either 5/12/23 or 5/13/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance. R10 expressed care concerns to R10's physician on 5/22/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance. R10's family expressed concerns about a transfer with injury that occurred on 5/27/23. The facility did not fill out a grievance form, thoroughly investigate, or provide follow-up and resolution of the grievance.

Inspectors wroteBased on staff interview and record review, the facility did not implement their abuse prevention policy and procedure for 2 (Certified Nursing Assistant (CNA)-F and CNA-G) of 8 staff reviewed during the caregiver program compliance check. The facility did not complete a current Background Information Disclosure (BID) form, Department of Justice (DOJ) letter, or Integrated Background Information System (IBIS) letter for CNA-F. The facility did not complete an out-of-state background check for CNA-G.

Inspectors wroteBased on staff interview and record review, the facility did not thoroughly investigate a fall to ensure the environment was as free of accident hazards as possible for 1 Resident (R) (R4) of 2 residents reviewed for falls. R4 had a fall with injury on 8/18/23. The facility did not complete a thorough investigation to determine a root cause analysis or complete staff education to minimize the likelihood of future falls.