Stoddard Baptist Nursing Home

Inspectors wroteBased on observations, medical record review and staff interviews for two (2) of six (6) sampled residents, facility staff failed to ensure interventions were implemented for a resident who was status post cervical laminectomy and required assistance from staff with transfers; and for a resident with a history of Dementia and Left Below the Knee Amputation (BKA) who required 2-person assistance while performing Activities of Daily Living (ADL) care. Residents' #34 and #35.

Inspectors wroteBased on observations, medical record review and staff interviews for one (1) of six (6) sampled residents, facility staff failed to provide a resident with food prepared by methods that conserve nutritive value, flavor, appearance, and that is palatable and attractive. Resident #35. A review of Resident #35's medical record revealed: Resident #35 was admitted to the facility on [DATE] with multiple diagnoses that included: Spinal Stenosis, Cervical Laminectomy and Chronic Obstructive Pulmonary Disease. An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15,' indicating the resident was cognitively intact. A review of the facility's resident lunch menu dated 11/17/25 documented: Cream of Mushroom Soup, Tuna Macaroni, Peas & Carrots, Crackers and Strawberry Yogurt. [...]

Inspectors wroteBased on observations, record reviews and staff interviews for one (1) of seven (7) sampled residents, the facility staff failed to ensure that a resident had adequate assistance while being transferred from the wheelchair to the bed in the resident's room and subsequently the resident sustained injuries and was transferred to the hospital emergency room. Resident #1.

Inspectors wroteBased on record reviews and staff interviews for two (2) of seven (7) sampled residents, the facility staff failed to report an allegation of abuse to the State agency in the required timeframe as evidenced by an incident involving a resident-to-resident altercation first documented by the facility on 02/25/25 but not reported to the State agency until 03/03/25. Resident #2 and #3.

Inspectors wroteBased on record reviews and staff interviews for one (1) of seven (7) sampled residents, the facility staff failed to develop a care plan for a resident who required a 2-person physical assist when transferring from the wheelchair to the bed. Resident #1.

Inspectors wroteBased on record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to ensure that Resident #52 received care to prevent pressure ulcer development that was first observed at a Stage 3. This deficiency resulted in actual harm to Resident #52 on 02/28/2024.

Inspectors wroteBased on record review and staff interview, for one (1) of 1 residents sampled for pain management, facility staff failed to ensure that Resident #243 received effective pain assessments/evaluation for a known left hip fracture.

Inspectors wroteBased on observations and staff interview, facility staff failed to serve foods under sanitary conditions as evidenced by hot foods temperatures that were below 135 degrees Fahrenheit (F) on six (6) of six (6) observations, two (2) of two (2) convection ovens, and two (2) of two (2) grease fryers that were soiled throughout, ready-to-eat (RTE), open bags of foods such as two (2) of two (2) packs of cold cuts, one (1) of two (2) bags of shredded yellow cheese, three (3) of five (5) packs of sliced yellow cheese, one (1) of one (1) bag of feta cheese, one (1) of one (1) jar of applesauce stored in the walk-in refrigerator, that were not labeled to indicate a use-by ' date, pieces of frozen chicken that were being thawed improperly, and a sanitize water solution in the 3 compartment sink that tested below the recommended 200 parts per million (PPM).

Inspectors wroteBased on record reviews and staff interviews, for four (4) of 41 sampled residents, facility staff failed to have documented evidence that they conducted thorough investigations. Resident #'s 192, 294, 244 and 63.

Inspectors wroteBased on record review and staff interviews, for two (2) of 41 sampled residents, facility staff failed to immediately notify the resident's primary physician or their representative when there was a change in the resident's condition that required physician intervention. Resident #52 and Resident #243.

Inspectors wroteBased on record reviews and staff interviews for one (1) of 41 sampled residents, facility staff failed to ensure Resident #192 was free from neglect as evidenced by the resident leaving the facility without staff knowledge.

Inspectors wroteBased on observations, record reviews and resident and staff interviews, for four (4) of 41 sampled residents, facility staff failed to implement its policies and procedures for reporting and investigating allegations or incidents of abuse and neglect. Resident #192, Resident #40, Resident #25 and Resident #294.

Inspectors wroteBased on record reviews and staff interviews, for two (2) of 41 sampled residents, facility staff failed to report the results of their investigations to the State Agency within 5 (five) working days of the incident. Resident #192 and Resident #294.

Inspectors wroteBased on record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to provide Resident #66's representative with written information that specified the duration of the state bed-hold policy before transfer to the hospital.

Inspectors wroteBased on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to complete a quarterly (every 3 months) assessment for Resident #72.

Inspectors wroteBased on record review and staff interviews for one (1) of 41 sampled residents, facility staff failed to have documented evidence a resident's admission Minimum Data Set (MDS) Assessment was completed as evidenced by not coding the resident's cognitive patterns in Section C. Resident #89.

Inspectors wroteBased on record review and staff interview, for two (2) of 41 sampled residents, facility staff failed to develop a care plan with goals and approaches to address a resident's use of a central intravenous (IV) line and a cholecystectomy tube and failed to implement a resident's care plan intervention for falls. Resident #66 and Resident #71.

Inspectors wroteBased on observation, record reviews, staff interviews, and a family interview, for one (1) of 41 sampled residents, the facility's staff failed to provide adequate supervision for a resident. As a result, the resident left the facility without staff knowledge (Resident #192).

Inspectors wroteBased on observation, record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to follow the physician's order to change Resident #66's peripherally inserted central catheter (PICC) line dressing every Friday.

Inspectors wroteBased on observations and staff interviews, for two (2) of two (2) oxygen storage rooms, facility staff failed to ensure that empty oxygen tanks were not stored in the same area as full oxygen tanks intended for patient use.

Inspectors wroteBased on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to promptly notify the ordering physician of radiology results that fell outside of clinical reference range. Resident #243.

Inspectors wroteBased on record review and staff interviews, facility staff failed to provide documented evidence that the Nurse Staffing Agency used to supplement the facility's nursing staff was operating in compliance with applicable Federal, State, and local laws and regulations, as evidenced by providing services in the District of Columbia (D.C.) on an expired business license. The facility's census on the first day of the survey was 90.

Inspectors wroteBased on record reviews and staff interviews, for three (3) of 41 sampled residents, facility staff failed to accurately document in the residents' medical record.

Inspectors wroteBased on record review and staff interview, for 12 out of 25 Infection Control policies and procedures, facility staff failed to have documented evidence that they were reviewed at least annually.

Inspectors wroteBased on record review and staff interviews, for two (2) of 41 sampled residents, facility staff failed to have documented evidence that the residents or their responsible party received education on Influenza vaccination. (Resident #4 and Resident #49).

Inspectors wroteBased on observations and staff interview, facility staff failed to maintain essential equipment in safe condition as evidenced by one (1) of one (1) defective food pellet warmer, and two (2) of four (4) burners from one (1) of one (1) gas stove that did not function when tested.

Inspectors wroteBased on observation, record review and staff interview, for two (2) of 41 sampled residents, facility staff failed to ensure that Resident #26 received timely treatment and care in accordance with professional standards of practice and the physician's orders for her right foot; and facility staff failed to assess Resident #32's skin every shift per the care plan. Subsequently, the resident was observed with cellulitis of left lower limb with edema. These failures resulted in actual harm to Resident #26 when it was determined that the resident's reddened right big toe (first observed on 07/14/22) further declined and resulted in amputation on 10/26/22.

Inspectors wroteBased on record review and staff interviews for four (4) of 41 sampled residents, facility staff failed to develop and implement comprehensive patient-centered care plans that included goals and approaches to meet resident's medical, physical, mental and psychosocial needs. Residents' #350, #32, #299, and #26.

Inspectors wroteBased on staff interview, the facility failed to maintain and implement an effective, comprehensive quality assurance and performance improvement (QAPI) program inclusive of all systems as evidenced by failing to identify areas for improvement and to develop and implement corrective and preventive actions. The resident census during the survey was 101.

Inspectors wroteBased on record review and staff interviews, for four (4) of 41 sampled residents, facility staff failed to determine whether residents had Advanced Directives (AD) and failed to provide residents or their representatives the right to formulate or refuse an AD. Residents' #55, #67, #69 and #248.

Inspectors wroteBased on record review and staff interviews, for three (3) of 41 sampled residents, facility staff failed to ensure that residents Minimum Data Set (MDS) assessments were coded to reflect of their status at the time of the assessments. Residents' #348, #69, and #68.

Inspectors wroteBased on record review and staff interview, for five (5) of 41 sampled residents, facility staff failed to revise the comprehensive care plans with new goals and approaches for: one resident who had a urinary tract infection (UTI); two residents who sustained falls; one resident's right foot cellulitis and gangrene; and one resident's new dialysis access site. Residents' #25, #80, #26, #68 and #79.

Inspectors wroteBased on observations and staff interview, facility staff failed to store and prepare foods under sanitary conditions as evidenced by food items including one (1) of one (1) container of potato salad, five (5) of five (5) containers of mashed potatoes, one (1) of one (1) pan of vegetable mix noodles, one (1) of one (1) pack of turkey bologna, one (1) of one (1) box of American cheese, and one (1) of one (1) pack of roast beef, that were not labeled or dated in one (1) of one (1) walk-in refrigerator, two (2) of two (2) soiled convection ovens, one (1) of one (1) [NAME]-Shaam oven that was soiled on the interior and exterior, one (1) of one (1) flat top grill that was stained on both sides, and food temperatures that tested below 135 degrees Fahrenheit (F) on five (5) of six (6) observations.

Inspectors wroteBased on observation, record review, and staff interview, for one (1) of 41 sampled residents, facility staff failed to ensure a resident's dignity and privacy as evidenced by failing to place a privacy cover over the resident's urine collection bag. Resident #298.

Inspectors wroteBased on record review and staff interview, for two (2) of 41 sampled residents, facility staff failed to implement its policies for conducting investigations of facility reported incidents as evidenced by failure to conduct a thorough investigation of: one resident's allegation of abuse; and one resident's unwitnessed fall, allegation of abuse, and elopement. Residents' #4 and #82.

Inspectors wroteBased on record review and staff interview, for two (2) of 41 sampled residents, facility staff failed to conduct a thorough investigation of one resident's allegation of abuse and one resident's unwitnessed fall, allegation of abuse, and elopement. Residents' #82 and #4.

Inspectors wroteBased on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to ensure that one resident had a physician's order for an indwelling catheter. Resident #298.

Inspectors wroteBased on observation and staff interview, for one (1) of 41 sampled residents, facility staff failed to administer medications within the professional standards of practice. Resident #99.

Inspectors wroteBased on record review and staff interviews, for one (1) of 41 sampled residents, facility staff failed to ensure that residents received care to promote the healing of existing pressure ulcers for Resident #350.

Inspectors wroteBased on record review and staff interview, for two (2) of 41 sampled resident, facility staff failed to identify and implement measures or approaches to reduce the risk of accidents (falls). Residents' #80 and #68.

Inspectors wroteBased on observation, record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to: develop and implement interventions for care and monitoring of his dialysis access site; and have an emergency kit (pressure bandage) at the bedside of Resident #79.

Inspectors wroteBased on record review and staff interview for two (2) of 41 sampled residents, the physician failed to adequately evaluate resident's condition and total program of care as evidenced by: no physician's order for an indwelling catheter for one resident and a physician progress note that inaccurately documented the physician's involvement in the assessment and care of one resident. Residents' #298 and #79.

Inspectors wroteBased on observation, record review, and staff interview, for one (1) of 41 sampled residents, facility staff failed to ensure that licensed nurses had the specific competencies and skill sets necessary to care for a resident's needs and assure resident safety when administering medications. Resident #99.

Inspectors wroteBased on observation, record review, and staff interview, for one (1) of 41 sampled residents, facility staff failed to: properly waste a discontinued narcotic and reconcile narcotics. Resident #24.

Inspectors wroteBased on record reviews and staff interviews, for one (1) of 41 residents, facility staff failed to take the action of notifying the psychiatrist as ordered, in response to a monthly MRR (medication regimen review) and to have an established, consistent location for the MRR forms to facilitate communication with the State Surveyors. Resident #60.

Inspectors wroteBased on observation, record review, and staff interview, in two (2) observations, facility staff failed to: store medications in accordance with professional standards of practice; and to date and initial Insulin vials.

Inspectors wroteBased on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to promptly notify the ordering physician of Resident #248's laboratory results that were outside of the clinical reference ranges. Resident #248.

Inspectors wroteBased on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to provide a resident with the necessary diagnostic services in a timely manner, resulting in the worsening of a right foot non-pressure related ulcer/wound that extended from the right big toe to midfoot. Resident #26.

Inspectors wroteBased on record review and staff interview, for one (1) of 41 sampled residents, facility staff failed to accurately document in Resident #79's medical record.

Inspectors wroteBased on observation and staff interview, in one (1) of five (5) medication administration observations, facility staff failed to maintain infection control practices when administering medications. Resident #99.

Inspectors wroteBased on record review and interview for one (1) of three (3) sample certified nursing assistants, the facility staff failed to ensure a certified nursing assistant received Dementia Management Training in 2019.

Inspectors wroteBased on observation, record review, and interview for one (1) of 34 sampled residents, the facility's staff failed to ensure one (1) was free from physical restraint. (Resident #108)

Inspectors wroteBased on record review and interview for one (1) of 34 sampled residents, the facility's staff failed to ensure one (1) resident's Care Plan was revised. (Resident #7).

Inspectors wroteBased on record review and staff interview for three (3) of 34 sampled residents, facility staff failed to show evidence of monitoring one (1) resident for specific behaviors to include: confusion, anxiety, agitation and restlessness, to monitor one (1) resident's side effects with the use of a psychotropic medication, and to provide evidence that one (1) resident was monitored while receiving Antipsychotic medications. Residents' #39, #93 and #120.

Inspectors wroteBased on observation and interview, it was determined that facility staff failed to prepare food in accordance with professional food safety standards as evidenced by two (2) of two (2) grease fryers that were soiled with leftover fried food residue, six (6) of seven (7) soiled, six-inch deep, one-quarter pans that were stored on a clean, ready-for-use shelf, and one (1) of one (1) four-inch deep pan and one (1) of one (1) one-eight pan that were dented throughout.

Inspectors wroteBased on observation and interview, it was determined that facility staff failed to maintain the call bell system in good condition as evidenced by one (1) of 30 call bell that failed to alarm as expected.