Hebrew Home of Greater Washington

In the surveyor’s words

From the most serious findings on record at Hebrew Home of Greater Washington, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 15, 2022

  PNC IJ 689 Based on surveyor review of clinical and administrative records and staff interviews, it was determined that the facility failed to put interventions in place to address the resident's wandering behavior and accurately assess the resident for the risk of elopement. As a result of this deficient practice, a cognitively impaired resident was able to exit the facility twice without staff knowledge or supervision, once on 7/21/2021 and again on 10/3/2021. The resident was found on 10/3/2021 near a busy road in close proximity to the facility. This finding was evident for 1 of 2 residents reviewed for elopement during a complaint survey and was identified during the investigation of facility reported incidents #MD 877 and MD 768. […]

• No harm, potential for more than minimal, patternF609Feb 7, 2025

  Based on review of facility reported incidents with documentation and interview, it was determined the facility failed to report allegations of abuse, neglect, and injuries of unknown origin within 2 hours of the allegation to the regulatory agency, the Office of Health Care Quality (OHCQ). This was evident for 18 (#631, #647, #646, #627, #641, #637, #621, #5, #620, #250, #94, #229, #157, #96, #278, #264, #77, and #48) residents of 60 facility reported incidents reviewed during an annual and complaint survey. The findings include: 1) On 1/27/25 at 10:12 AM a review of facility reported incident MD00188273 revealed Resident #631 alleged that he/she was raped 5 nights prior by multiple guys. On 1/26/23 at 16:25 (4:25 PM) the daughter informed facility staff. […]

• No harm, potential for more than minimal, patternF610Feb 7, 2025

  Based on review of facility reported incidents and staff interview, it was determined the facility failed to provide documentation that allegations of abuse were thoroughly investigated. This was evident for 9 (#629, #638, #640, #366, #625, #5, #622, #87, and #619) residents of 60 facility reported incidents reviewed during a recertification/complaint survey. The findings include: The Minimum Dats Set (MDS) is a standardized and comprehensive assessment screening tool used to identify resident's individual needs and areas of concern. BIMS stands for Brief Interview for Mental Status. […]

• No harm, potential for more than minimal, patternF812Feb 7, 2025

  Based on observation, interview and record review it was determined the facility failed to: 1.) ensure the labeling, dating, and expiration of nourishment items, 2.) ensure a sanitary environment in the nourishment refrigerator and 3.) ensure dishwashing machines met the minimum required manufacturer temperatures recommended for sanitization. This was evident for: 1.) 1 reach-in refrigerator in 1 out of 2 of the facility's kitchens, 2.) 1 nourishment refrigerator in 1 out of 2 of the facility's kitchens, and 3.) 3 out of 4 dishwashing machines, during the facility's recertification/complaint survey. […]

• No harm, potential for more than minimal, patternF842Feb 7, 2025

  Based on medical record review and interview, it was determined that the facility failed to maintain complete and accurate medical records in accordance with accepted professional standards. This was evident for 9 (Resident #366, #63, #367, #615, #626, #628, #644, #649, and #650) resident of 108 residents reviewed during the recertification/complaint survey. The findings include: A medical record is the official documentation of a healthcare organization. As such, it must be maintained in a manner that follows applicable regulations, accreditation standards, professional practice standards, and legal standards. All entries to the record should be legible and accurate. 1) On 1/29/25 at 11:49 AM a review was conducted of Resident #366's medical record. […]