Walter Reed Post Acute

In the surveyor’s words

From the most serious findings on record at Walter Reed Post Acute, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812May 21, 2021

  Based on observation and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in that the facility failed to ensure dietary staff cleansed food preparation areas with an appropriate strength sanitizer, failed to change gloves and perform hand hygiene before touching clean dishes and before serving food. This deficient practice had the potential to affect all the residents in the facility. Findings included: Observation on 05/18/21 at 9:19 AM, Dietary Aide (DA)27 cleansed the counter surfaces in the kitchen with a solution in a red bucket labeled Sanitizer solution. […]

• No harm, potential for more than minimal, isolatedF685Aug 22, 2024

  Based on observation, resident interview, staff interview, clinical record review, and review of facility documents, the facility's staff failed to assist the resident to obtain vision services for 1 of 45 residents (Resident #85), in the survey sample. The findings included: Resident #85 was originally admitted to the facility 11/16/23 after an acute care hospital stay. The current diagnoses included Macular Degeneration. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 8/5/2024 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #85 cognitive abilities for daily decision making were intact. […]

• No harm, potential for more than minimal, isolatedF690Aug 22, 2024

  Based on observation, staff interview, clinical record review, and review of facility documents, the facility's staff failed to ensure a leg strap was available to secure to a resident's leg to prevent the Foley (brand) catheter from dislodging or being pulled and the facility staff failed to date resident's Foley bag and Foley catheter for 1 of 45 residents (Resident #29), in the survey sample. The findings included: Resident #29 was originally admitted to the facility 02/22/2016 and readmitted [DATE] after an acute care hospital stay. The current diagnoses included; retention of urine. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/17/24 coded the resident as not having the ability to complete the Brief Interview for Mental Status (BIMS). […]

• No harm, potential for more than minimal, isolatedF558May 21, 2021

  Based on observations, record review and interviews, the facility failed to accommodate the need of one (Resident (R) 20 of two residents reviewed for accommodation of needs. Specifically, the facility failed to ensure R20, who had contractures of both hands, was provided with a call bell system that R20 could use to signal for assistance and that the call bell was within reach when in bed. Findings include: Review of R20's Face sheet in the Electronic Medical Record (EMR) under the Admission tab revealed R20 was admitted on [DATE]. Review of R20's EMR physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF580May 21, 2021

  Based on observation, interview, and record review, the facility failed to notify the physician to obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of R65's quarterly Minimum Data Set (MDS) assessment found under the MDS tab of the Electronic Medical Record (EMR) with an assessment reference date (ARD) of 03/19/21, revealed a Brief Interview Mental Status (BIMS) score of 15 which indicated cognitively intact. The MDS did not indicate any pressure ulcers. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview with the Assistant Director of Nursing and observation of R65's sacrum on 05/20/21 at 3:00 PM, the Assistant Director of Nursing (ADON) stated that she had no knowledge of an open area to R65's sacrum area. […]