Complete Care at Germantown

In the surveyor’s words

From the most serious findings on record at Complete Care at Germantown, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Jan 10, 2022

  Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable disease and infections such as COVID-19. This created a reasonable likelihood for serious harm to all 67 residents residing within the facility at the time of the outbreak on 12/23/21. At the time of survey, this outbreak has affected 8 residents and 18 staff. The facility did not: *Recognize when an outbreak had occurred and did not implement appropriate precautions to prevent the further spread of infection. * Screen all residents for signs and symptoms of COVID-19 daily and increase screening to every shift once the outbreak was identified. […]

• Immediate jeopardy, isolatedF686Sep 8, 2021

  Based on interview, observation and record review, the facility failed to ensure 4 (R31, R55, R14, and R21) of 4 residents reviewed for pressure injuries (PI) received care consistent with professional standards of practice, to prevent pressure injuries and residents with pressure injuries receive necessary treatment and services, to promote healing, prevent infection and prevent new injuries from developing. R31 was admitted to the facility with no wounds and with a high risk for skin breakdown. R31 had no care plan in place to prevent skin breakdown. R31 developed multiple pressure injuries including a Stage 4 and unstageable pressure injury to the buttocks area, right and left hips, heels, and feet. […]

• Immediate jeopardy, isolatedF693Sep 8, 2021

  Based on interview, observation and record review, the facility failed to prevent dehydration for 1 (R31) of 3 residents reviewed on enteral feeding. R31 had a Percutaneous endoscopic gastrostomy (PEG) tube placed 3/26/21. The facility failed to give R31 enough fluids which resulted in multiple hospitalization s for [CONDITION(S)]. The facility did not follow specific orders given to the facility to prevent [CONDITION(S)] and did not monitor or order electrolyte labs that showed high and critical levels of Na+ (sodium). […]

• Immediate jeopardy, isolatedF689Feb 25, 2021

  Based on record review and staff interview, the facility did not ensure a resident received supervision to prevent accidents for 1 Resident (R) (R1) of 1 residents reviewed for supervision and interventions to prevent accidents. R1 was severely cognitively impaired, at risk for falls and required assistance of staff for mobility. R1 had difficulty making needs known and was taking three prescribed blood-thinning medications. R1 had an unwitnessed fall on [DATE] and the facility did not conduct an investigation to determine the circumstances surrounding the fall and how to prevent a similar occurrence in the future. R1 had another unwitnessed fall from the wheelchair on [DATE] with injuries to face, and the facility did not implement interventions timely. […]

• Actual harm, isolatedF689Jul 20, 2022

  Based on observation, interview, and record review, the facility did not ensure 2 (R8, R10) of 3 residents reviewed who are at risk for falls received the necessary services and supervision to prevent an injury from a fall or conduct through fall investigations. *The facility did not thoroughly investigate to determine a root cause analysis of R8's falls on 4/14/22, 4/21/22, 5/7/22, and 7/7/22. On 5/7/22, R8 fell while attempting to toilet themselves, sustaining a left femur fracture which required hospitalization with surgical intervention. *R10 sustained falls on 5/4/22 and 5/8/22 that were not thoroughly investigated by the facility to determine a root cause analysis. […]