Georgetown Nursing and Transitional Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food safety for one of one kitchen (identifier) reviewed for food safety requirements. The facility failed to ensure that all expired items were removed from storage. The facility failed to ensure all items were properly labeled and dated. The facility failed to store dented cans separately from other canned items. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for two of two dumpsters (identifiers) reviewed for refuse. The facility failed to ensure that dumpsters were covered and that surrounding areas were free from debris. This failure could place residents at risk of exposure to pests.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 3 of 10 residents (Resident #36, Resident #58, and Resident #67) reviewed for rights. The facility failed to ensure LVN A and CNA B knocked on Resident #36, Resident #58, and Resident #67's doors when going into the residents' rooms. These failures could place residents at risk of feeling like their privacy was being invaded or the facility was not their home.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 8 (Resident #15, #25, and #39) residents reviewed for accommodations. The facility failed to ensure call lights were within reach while in resident rooms for Resident #15 and Resident #39. The facility failed to ensure dining room tables were appropriate height for wheelchairs for Resident #25. These failures could place residents at risk of injury, for not receiving timely care, or a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry out Activities of Daily Living receive the necessary services to maintain grooming and personal hygiene for 4 of 12 residents (Resident #19, Resident #22, Resident #28 and Resident #6) reviewed for Activities of Daily Living. The facility failed to ensure Resident #19 and Resident #28's facial hair was shaved from 04/28/2025 and 04/29/2025. The facility failed to ensure Resident #6 and Resident #22 were provided their showers 3 times a week as scheduled. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to dispose of open stored perishable food products and damaged food. 2. The facility failed to properly label and date food products in the dry storage pantry, refrigerator, and freezer. 3. The facility failed to ensure Dishwasher H and General Manager wore beard restraints properly while performing duties throughout the kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Volunteer P) of 3 volunteer members and 4 of 8 residents (Resident # 8, #15, #33, and #57) reviewed for infection control. The facility failed to ensure Volunteer P conducted hand hygiene during resident dining services. 1. The facility failed to ensure 2 of 3 staff (MA E and MA F) disinfected the blood pressure cuff between resident use for 3 of 4 residents (Resident # 8, #33, and #57) reviewed during medication pass. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms for 1 (Residents #9 ) of 5 residents reviewed for restraints. The facility failed to ensure that bedrails were not used on the side of Residents #9 bed as Resident #9 requested assistance getting out of bed when the rails were up. This failure could result in residents having physical restraints used that limited their movement without being evaluated for the medical need.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 8 residents (Resident # 15) reviewed for range of motion. The facility failed to ensure treatment and interventions for Resident #15's contractures of the right hand. This failure could place the resident at risk for not receiving the care and services to prevent worsening contractures that can cause pain and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs were labeled in accordance with currently accepted professional principles, store all drugs in locked compartments, and provide separately locked, permanently affixed compartments for storage of controlled drugs for 3 of 6 (100-hall medication care, 100-hall wound care cart and 100-hall nurses' cart) medication carts reviewed for drug storage and labeling. 1. The facility failed to ensure all medications that required a prescription we labeled with a resident name for 2 of 6 medications carts (100-hall wound care cart and 100-hall nurses' cart). 2. The facility failed to ensure the 100-hall wound care cart was locked when unattended by the IP nurse, who also was the facility's wound care nurse. 3. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 6 residents reviewed for falls. The facility failed to put assessments and/or neuro checks in place for Resident #1 after she was sent to the ER after a fall on 03/12/25 at approximately 6:00 a.m. and returned to the facility on [DATE] at approximately 10:23 a.m. with diagnoses of an orbital floor fracture, lip or mouth laceration (cut through the skin), hematoma (collection of blood trapped outside of a blood vessel (bruise or a contusion)) to the left side of her head, and a maxillary sinus (midface) fracture. An IJ was identified on 03/14/2025. The IJ template was provided to the facility on [DATE] at 9:20 p.m. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #2) of 6 residents reviewed for oxygen use and storage. The facility failed to ensure Resident #2's nebulizer mask in her room was stored away when it was not in use on 03/14/25. This deficient practice could place residents at risk of infection.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to protect the residents' right to be free from abuse for one (Resident #1) of three residents reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse on 02/03/25 when CNA A told the resident, You shouldn't even act like this, I want to put you to bed but you're not acting right with all the yelling and screaming and yelled repeatedly at the resident. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/03/25 and ended on 02/07/25 . The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for abuse and psychosocial harm.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the residents had the right to be free from involuntary seclusion and any physical restraint not required to treat the resident's medical symptoms for one (Resident #1) of three residents reviewed for involuntary seclusion. The facility failed to ensure Resident #1 was free from involuntary seclusion on 02/03/25 when CNA A pushed Resident #1, who was sitting in a wheelchair, into her room, closed the door, and held the door closed with two hands while Resident #1 was heard yelling let me out. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 02/03/25 and ended on 02/27/25. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for seclusion and psychosocial harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and sanitation. 1. The facility failed to ensure food and beverages in refrigerator unit #2 and 3 and the walk-in freezer, were covered, labeled, and dated. This failure could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 5 of 16 residents (Resident #4, Resident #7, Resident #8, Resident #14, and Resident #35), reviewed for care plans. -The facility failed to ensure Resident #4's care plan accurately reflected her antidepressant medication. -The facility failed to ensure Resident #7's care plan reflected her code status. -The facility failed to ensure Resident #8's care plan accurately reflected his antidepressant medication. -The facility failed to ensure Resident #14's care plan accurately reflected the current g-tube status. -The facility failed to ensure Resident #35's care plan accurately reflected the current diet, cognitive status, and pressure ulcer status. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, he or she prefers for 2 (Resident #4 and Resident #7) of 5 residents reviewed for informed consent for treatment options. The facility failed to: 1. obtain a signed informed consent for the use of Duloxentine (an anti-depressive) for Resident #4. 2. obtain a signed informed consent for the use of Aripiprazole (an antipsychotic medication) for Resident #7. This failure could affect all residents by placing them at risk of receiving psychotropic medications without informed consent which could cause decrease quality of life and increase the risk of injury and violate the rights of residents to make informed decisions related to care.