Germantown Home

Inspectors wroteBased on review of facility policy, interviews with staff, and review of clinical records, it was determined that the facility failed to develop person-centered, comprehensive care plans for two of 35 residents reviewed (Residents R125 and R183). Findings Include:Review of facility policy titled, Baseline Care Plan with a revision date of January 2026 states, Purpose: The Baseline Care Plan is intended to promote continuity of care, Person Centered Care and communication among nursing home staff. Policy: A Baseline Care Plan will be developed and implemented, beginning with the resident's initial interdisciplinary assessments. It will include the instructions needed to provide continuity of person-centered care that meet professional standards of quality care. Completion and implementation of the Baseline Care Plan will be done within the 48 hours of a resident's admission. [...]

Inspectors wroteBased on a review of facility policies, review of clinical records, and staff interviews, it was determined the facility failed to maintain complete and accurate resident records for two of 35 residents reviewed (Resident R9 and R14).

Inspectors wroteBased review of facility documentation, facility policy, clinical records, and interviews with staff, it was determined that the facility failed to ensure that a resident's care plan was revised timely to address ongoing and escalating aggressive behaviors for one of two sampled residents. (Resident R1)

Inspectors wroteBased on observations, review of clinical records, review of facility policy, and interview with staff, it was determined that the facility did not develop and implement a comprehensive, resident-centered care plan for seven of 35 residents reviewed related to wounds and Enhanced Barrier Precaution's. (Resident R36, R71, R114, R156, R24, R187, and R41)

Inspectors wroteBased on observation, clinical record review, review of facility policy and staff interview, it was determined that the facility failed to ensure that urinary catheter bag were properly position to prevent contact with the floor for one of one residents review with an indwelling urinary catheter. (Resident Review of facility policy titled Urinary Catheter Care, last reviewed on June 20, 2019, revealed the purpose of the policy is to reduce the risk of the indwelling urinary catheter becoming the source of infection and to reduce the transmission of infection to or between residents/ participants with indwelling urinary catheters. Furthermore, Drainage Bags should never touch the floor. [...]

Inspectors wroteBased on review of clinical records, review of policies, and interview with staff, it was determined that facility did not ensure to provide and/or document the provision of pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the influenza for 51 of 54 residents reviewed (Resident R41, R26, R28, R29, R30, R34, R42, R3, R43, R50, R12, R64, R65, R73, R75, R86, R97, R114, R117, R119, R120, R132, R136, R140, R141, R143, R11, R146, R151, R154, R171, R8, R178, R18, R24, R77, R107, R130, R139, R1, R152, R162, R173, R175, R21, R22, R25, R10, R27, R32, R35)

Inspectors wroteBased on review of clinical records, review of policies, and interview with staff, it was determined that facility did not ensure to provide and/or document the provision of pertinent information regarding the immunizations to the resident or the resident's representative such as the benefits and potential side effects of the covid-19 immunizations for seven of seven residents reviewed (Residents R120, R24, R141, R43, R145, R156, R83)

Inspectors wroteBased on clinical record review revealed that the facility failed to ensure that a rational was documented related to pharmacy recommendations for one of 35 residents reviewed. (Resident R2)

Inspectors wroteBased on review of facility documentation, review of clinical record, and staff interview, it was determined that the facility failed to accurately complete a resident assessment for one of 35 residents reviewed (Resident R37). Findings Include: Review of Resident R37's clinical record revealed a progress note dated June 5, 2025, that the resident was assessed and evaluated by the hospice care team. Resident R37 was subsequently admitted on to hospice with a diagnosis of cerebral atherosclerosis (build-up of plaque in the blood vessels of the brain occurs). Review of Resident 37's clinical record revealed a physician order dated June 5, 2025, for hospice care services. [...]

Inspectors wroteBased on review of facility documentation and interview with staff, it was determined the facility failed to provide timely notice on non-medical coverage (NOMNC) for one of three residents reviewed. (Resident 117) Findings Include: Review of Resident R117's clinical records shows the resident was re-admitted to the facility on [DATE]. Resident R117 remained at the facility after his last day of coverage was September 2, 2024. Review of the social service note from September 18, 2024 revealed Note Text: Resident Representative, notified on September 18, 2024 of resident's last coverage date of September 3, 2024. Resident Representative informed of right to appeal last coverage date. Resident Representative stated they would like resident to continue working with therapy. [...]

Inspectors wroteBased on observation, clinical record review, and interview with staff and residents, it was determined that the facility did not ensure that resident assessments accurately reflected resident status related to use of a urinary catheter and discharge status for two of 38 records reviewed (Residents R50 and R178).

Inspectors wroteBased on review of facility policy, observation, clinical record review, and interview with staff and residents, it was determined that the facility did not develop a comprehensive care plan related oxygen use for one of 35 records reviewed (Resident R167).

Inspectors wroteBased on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not revise and update the resident's plan of care related to urinary catheter use for one of 35 records reviewed (Resident R50).

Inspectors wroteBased on review of facility policy, observation, clinical record review and interview with staff and residents, it was determined that the facility did not ensure that services were provided to maintain hearing and vision for two of 35 records reviewed (Residents R53 and R142).

Inspectors wroteBased on staff interviews and a review of employee credentials, it was determined that the facility failed to employ a qualified director of food and nutrition services (Employees E9).

Inspectors wroteBased on review of facility policy, clinical record review and interview with staff, it was determined that facility failed provide resident with pressure injury measures to prevent the development or worsening of pressure injury for one resident. (Resident R1)