Every finding on record at Ascension Living Carroll Manor

Based on observations and resident interviews, the facility staff failed to maintain a safe and comfortable environment by not ensuring facility temperatures ranged from 71 to 81 Fahrenheit. As evidenced by four (4) of four residents who had respiratory diagnoses and/or were prescribed oxygen therapy, whose room temperatures ranged from 82 - 90 Fahrenheit after the facility staff turned off the HVAC system for repair. (Residents #1, #4, #196, and #199) The findings included: According to the Weather Channel, on June 10, 2026, the temperature in the District of Columbia ranged between 73 and 90 Fahrenheit. https://weather.com/weather/monthly/l/c4025fdf0177c872b7fc2e0d09e7c523995ef49e21145e2d2438fe08649ca9e81. Resident#1 was admitted to the facility on [DATE]. The resident had multiple active diagnoses, including Pulmonary Embolism without Acute Cor Pulmonale.An admission Minimum Date Set assessment dated [DATE] documented, in part, that the resident had a Brief Interview for Mental Status summary score of 15, indicating intact cognitive status. The resident was coded for requiring substantial/maximum assistance from staff for activities of daily living. A care plan dated 05/19/26 documented in part, Problem-Resident requires oxygen therapy related to Shortness of Breath, Approaches (Interventions)- administer oxygen at 2 liters per nasal cannula. Observe oxygen precautions, monitor and report signs of hypoxia, and position the resident in a sitting position for optimal breathing.During an observation at approximately 11:30 AM on 06/10/26, Resident#1 was noted in her room lying in bed. The resident was alert and oriented to name, place, and time. The resident was also receiving oxygen at 2 liters via nasal cannula per oxygen concentrator. When the resident was asked how she was doing? The resident stated, My room is hot. At the time of the observation, Employee #8 (Maintenance Mechanic) took the temperature of the resident's room using a laser thermometer. The resident's ambient room temperature was measured to be 90 Fahrenheit. Employee #8 stated that contractors were currently on-site working on the HVAC system. 2. Resident#4 was admitted to the facility on [DATE] with multiple diagnoses, including Personal History of Other Malignant Neoplasm of Bronchus Lung, Chronic Obstructive Pulmonary Disease, Cardiac Defibrillator, and Generalized Muscle Weakness. A quarterly Minimum Data Set assessment dated [DATE] documented, in part, that the resident had a Brief Interview for Mental Status summary score of 15, indicating intact cognitive status. The resident was also coded for being dependent on staff assistance with activities of daily living. A care plan dated 04/26/26 documented in part, Problem-[Resident's name] has potential for Shortness of Breath and/or respiratory complications related to history of diagnosis Chronic Obstructive Pulmonary Disease/Emphysema.Approach (Intervention)-Assess contributing factors or triggers to respiratory distress and take corrective action, Monitor for complications such as dyspnea, shortness of air[breath], cyanosis, or tachypnea, monitor oxygen saturation and administer oxygen per physician orders. During an observation at approximately 12 PM on 06/10/26, Resident #4 was observed lying in bed, alert and oriented to name, place, and time. When was the resident asked how she was doing? The resident stated, I'm not comfortable because it's hot in here. At the time of the observation, Employee #8 took the temperature of the resident's room using a laser thermometer. The resident's ambient room temperature was measured to be 88.2 Fahrenheit. Employee #8 stated that contractors were currently on-site working on the HVAC system. 3. Resident #196 was admitted to the facility on [DATE] with multiple diagnoses, including Chronic Respiratory Failure with Hypoxia, Obstructive Sleep Apnea, Asthma, Paraplegia, and Morbid Obesity. A care plan dated 05/22/26 documented in part, Problem-Resident requires oxygen therapy related to asthma and history of hypoxia.Approaches (Interventions)- monitor and report signs of hypoxia, monitor and document respiratory status, provide calm environment free from stimuli to reduce/prevent anxiety.A care plan dated 05/26/26 documented in part, Resident is at risk for Shortness of Breath/Respiratory Distress related to asthma.Approaches (Interventions)- administer oxygen at 2 liters per nasal cannula, monitor and report signs of respiratory distress, monitor lung sounds every shift.An admission Minimum Data Set assessment dated [DATE] documented, in part, that the resident had a Brief Interview for Mental Status summary score of 15, indicating intact cognitive status. The resident was coded for requiring partial and total assistance from staff for activities of daily living, shortness of breath or trouble breathing while lying flat, and using oxygen therapy.An observation at approximately 12:15 PM on 06/10/26 revealed Resident#196 in her room, lying in bed with the head of the bed elevated. The resident was alert and oriented to name, place, and time. Additionally, the resident appeared to have sweat on her forehead and chest. The resident was asked if she was sweating. The resident stated, Yes, because it is very hot in here. I couldn't sleep last night. Also, an oxygen concentrator was observed that was not in use. The resident stated, I only use oxygen when I need it. I don't need it right now. And when they [nurses] turn it [oxygen concentrator] on, the room gets hotter. And I'm already miserable with the temperature of the room right now. At the time of the observation, Employee #8 took the temperature of the resident's room using a laser thermometer. The resident's ambient room temperature was measured to be 88.2 Fahrenheit. Employee #8 stated that contractors were currently on-site working on the HVAC system. During a face-to-face interview at approximately 12:45 PM on 06/10/26, Employee #9 (Director of Maintenance) stated that the HVAC system was turned off this morning (6/10/26) to repair a leaking pipe. When asked how will they address the excessive ambient temperatures in residents' rooms? The employee stated that the work on the HVAC system would be completed today by 1 PM. The facility would cool down approximately 2 after the repair is completed. The employee stated that they had about 3 portable fans in residents' room. And they planned to purchase 10 more portable fans for other residents' rooms. It should be noted that the employee failed to provide the specific time the HVAC system was turned off on 06/10/26. And the facility did not purchase an additional 10 portable fans. During a face-to-face interview at approximately at 12:50 PM, on 06/10/26 Employee #3 (RN/Unit Manager) stated that they were offering cool wash clothes and providing hydration (cold water, juice, popsicles and sherbet) for residents to address the elevated temperatures in the facility. During a face-to-face interview at approximately 1PM on 06/10/26, Employee #1 (Administrator) stated she was not aware the HVAC system had been turned off or that the resident's room had excessive temperatures. She said that she was just coming into work today, but she would speak with her staff to find out when the HVAC was turned off. Additionally, the employee stated that she will make the survey team aware of her findings. It should be noted that the Administrator did not inform the survey team of her findings. 4. Resident #199 was admitted to the facility on [DATE] with multiple diagnoses, including Chronic Obstructive Pulmonary Disease, Chronic Respiratory Failure with Hypoxia, and Need for Assistance with Personal Care. A care plan dated 05/30/26 documented in part, Problem- Resident requires oxygen therapy related to respiratory failure.Approaches (Interventions)-Administer oxygen at 4 liters via nasal cannula.Keep room cool.monitor and report signs of hypoxia.An admission Minimum Data Set assessment dated [DATE] documented, in part, that the resident had a Brief Interview for Mental Status summary score of 15, indicating intact cognitive status. The resident was coded as requiring partial to total assistance from staff for activities of daily living; shortness of breath or trouble breathing while lying flat; shortness of breath or trouble breathing with exertion; and use of oxygen therapy.During an observation at approximately 3:45 PM on 06/10/26, Resident#199 was in her room, lying in bed with the head of the bed elevated. When the resident was asked, How was she feeling? She stated, I'm hot. At the time of the observation, Employee #8 took the temperature of the resident's room using a laser thermometer. The resident's ambient room temperature was measured to be 85 degrees Fahrenheit. During a face-to-face interview at approximately 4 PM on 06/10/26, Employee #8 stated that the contractors on-site today to repair the HVAC system did not complete the repair. And they would return on 06/11/26 to continue working on the HVAC system. Additionally, the employee stated that the facility will order spot coolers (portable air conditioning units) for Units 2, 3, 4, and 5. Please note: Because Unit 1's temperature levels ranged between 78 and 81 Fahrenheit, the facility did not order a portable air conditioner for that unit on 06/10/26. Based on these findings, an Immediate Jeopardy (IJ-L) was identified at 42 CFR 483.10, Resident Rights, F584, Safe/Clean/Comfortable/Homelike Environment on June 10, 2026 at 7PM.The facility's staff failed to provide a safe and comfortable environment with temperature levels ranging from 71 to 81 degrees Fahrenheit (F) in resident rooms and common areas. The findings revealed that the potential for serious harm was likely to occur as extreme/excessive heat and/or temperatures may likely result in compromised respiratory state and/or hyperthermia for Residents' #1,#4,#196,and #199 who were dependent on supplemental oxygen. The facility's Administrator submitted a corrective action plan to the Survey Team that was accepted on June 11, 2026 at 2:14 AM that documented the following: 1. Corrective action for residents noted to have been affected by the deficient practice. The Facilities Director contacted [vendor named]. to repair corroded pipe. On 6/10/26 At 7:30 am the vendor arrived at the community. Corroded Pipe was replaced. The chiller was turned off on 6/9/26 at 7:00pm was turned back on at 12:30 pm on 6/10/26. Ambient room temperatures returned to acceptable range by 7:00 pm on 6/10/26. A work-order was submitted to United Rentals at 12:18pm on 6/10/26 for temporary cooling units to be delivered to the facility by the Senior Director of Operational Excellence, which did not arrive. The Facilities Manager started to attempt to contact United Rentals for an estimated time of arrival at 17:07, 17:09, twice at 17:52, and again at 17:55. Unfortunately, United Rentals never responded to the calls. The Facilities Manager then called Axis at 1821 .The Account Manager from Axis responded to the Facilities Manager at 18:25. At that time, a work order was placed at 18:25 on 6/10/26 with Axis to obtain (6) spot coolers. The [vendor named]delivered a total of (6) spot coolers at approximately 8:20pm for the units. The Spot Coolers were placed on each of the units by 9:30 pm on 6/10/26 as a back up to maintain the temperatures. Facilities team began taking ambient room temperatures every hour beginning at 11:00 am for Resident Rooms 322, 327, 324, 330, 342, 343, 355, 331, 345, 526, 621, 515, 501, 222, 224, 226, 442, 444, 446, 451, 542, 545, 553, 554, 556 until appropriate temperatures are maintained. On 6/10/26 in house RNs and LPNs assessed all residents with oxygen therapy by 6:00 pm . No significant respiratory findings noted. Residents were made comfortable and provided drinks and cool wash cloths. Sherbet was added to the lunch meal provided to residents as additional dessert by nutrition services to residents who wished to have it. Activities staff provided popsicles to residents on 6/10/26 at 2:00 pm on all floors On 6/10/26, in house nursing Associates passed additional ice water to residents, cold washcloths were provided to residents, ice tea was made by nutrition services and offered in addition to the water provided to all residents able to drink by mouth. Available fans were provided to residents in rooms 515, 521 and 233 by the nursing staff on 6/10/26 by the Director of Nursing by 12:00 pm. On 6/10/26 Residents in room [ROOM NUMBER] and 528 were temporarily moved to 249 and 251 for increased comfort in temperature by the Director of Nursing. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? Ambient Temperatures for all resident rooms located on the 2nd floor, 3rd floor, 4th floor, 5th floor and 2nd floor dining room, 3rd floor dining room, 4th floor dining room, 5th floor dining room, 2nd floor, 4th floor and 5th floor common areas, hallways, hallway vents and elevator areas were checked and by Facilities Management team every 1 hour starting at 11am. All other residents in the community were evaluated by in house RNs and LPNs on 6/10/26 by 12:00 midnight and no significant findings noted. The Medical Director was notified by the Director of Nursing on 6/10/26 at 9:09 pm. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. All facilities management employees will be re-educated on the importance of ensuring that all patient areas are within regulatory temperature range of 71 to 81 degrees Fahrenheit and preventative measures are put in place prior to Maintenance mechanics being conducted to maintain appropriate temperatures by the Executive Director on 6/10/26 by 11:30pm Ad Hoc QAPI was held with the Senior Director of Operational Excellence, Chief Operations Officer, Director of Clinical Operations, Director of Nursing, Executive Director, Director of Clinical Operations/Regulatory, Director of Business Operations on 6/10/26 at 8:30pm. The Ad Hoc QAPI committee reviewed the existing Emergency planning manual section P: Severe Weather/Extreme Temperatures/Winter [NAME] on 6/10/26 and updated it to be more specific to planning. 4. Ongoing Monitoring Under the direction of the Quality Assurance and Process Improvement (QAPI) Committee, the Facilities Director or designee will audit ambient room temperatures every hour x 48 hours then every 8 hours x 3 days, then weekly ongoing to ensure the ambient temperature is maintained. Audits will be submitted and reviewed by the QAPI committee for management of ongoing compliance and will continue until otherwise determined by QAPI. The administrator is responsible for ensuring ongoing compliance. Date of Compliance: 6/10/26.Verification for the removal of the immediacy was performed by the Survey Team onsite on June 11, 2026, at 4PM.Cross Reference 22B DCMR Sec. 3238.3

Based on observation, record review, and staff interviews, the facility staff failed to provide the necessary treatment and services to prevent the development and progression of pressure ulcers (bedsores) for two (2) of two residents who developed pressure ulcers that were first observed at advanced stages Residents # 150 and #87. 1. Resident #150 was admitted to the facility on [DATE] with multiple diagnoses including Fracture of First Lumbar Vertebra, Abnormalities of Gait Mobility, Generalized Muscle Weakness, Severe Protein-Calorie Malnutrition, and Need for Assistance with Personal Care. An admission nursing progress note dated 04/09/26 at 6:06 PM documented in part, Resident is alert, oriented and verbally responsive. She's able to make his [her] needs known. Respiration is even and unlabored with no signs of respiratory distress. Skin is warm to touch, redness and dryness noted towards perineal, right groin and sacral area. Nursing staff will continue with the current plan of care, she remains in a stable condition. Vital signs: blood pressure 122/78, pulse 74, temperature 98, 18, oxygen saturation on room air 98%. admission skin evaluation forms dated: 04/09/26 at 10:48 PM documented in part, Spine Thoracic Lumbar surgical site with 14 staples. Treatment-monitor every shift. Occurred where - [local hospital's name]. 04/09/26 at 10:55 PM documented in part, Sacral Ulcer with redness/Moisture Acquired Skin Damage. Treatment-Cleanse sacral area with normal saline apply z-guard after incontinent care. Occurred where - [local hospital's name]. Stage-2. 04/09/26 at 11:18 PM documented in part, Right Groin Moisture Associated Skin Damage. Treatment area was blank. Occurred where - [local hospital's name]. A physician order dated 04/09/26 instructed in part, Shower Day twice weekly on Tuesday and Fridays 3PM-11PM shift. A Braden Scale (assessment tool) dated 04/09/26 documented that the resident had a pressure sore risk score of 14, indicating that the resident was at moderate risk for developing a pressure ulcer. Care plans dated 04/09/26 documented in part, Problem-[Resident's name] needs assistance with daily ADL care related to recent hospitalization, difficulty in walking and other lack of coordination. Approaches (Intervention)- Bed Mobility- I need extensive assistance with 1 person staff support. Bathing- I need extensive assistance with 1 person staff support. I prefer a bed bath. Problem-[Resident's name] has altered elimination to incontinence of bowel and bladder. Approaches (Intervention)-Provide toileting assistance every shift, assess and report signs of impaired skin integrity or breakdown. Problem –[Resident's name] is at risk for pressure ulcers and other skin-related injuries.Approaches (Intervention)- Braden scale to be completed, observe skin for redness and breakdown during routine care, use pressure relieving devices, cushion on the wheelchair., follow community skin care protocol, treatment as indicated.pressure reducing mattress. A history and physical dated 04/10/26 documented in part, This is a [AGE] year-old female with complex medical history. Diagnoses: Stage 1 Pressure Ulcer in Sacral Region. Plan-offloading protocol, barrier cream, wound consult nurse, reposition every 2 hours. A physician order dated 04/10/26 instructed, Weekly skin check by a licensed nurse on Tuesday 3 PM to 11 PM.for skin monitoring. A Braden Scale (assessment tool) dated 04/16/26 documented that the resident had a pressure sore risk score of 13 indicating that the resident was at moderate risk for developing a pressure ulcer. A document for certified nursing assistants titled, Daily Charting dated 04/21/26 documented in part, Description- bathing support provided, Time 3 PM - 11:30 PM, Status-One-person physical assist, Guidance-check resident skin for rashes, redness, wounds, bruises, if any problems noted, you must notify the nurse, Description-Does the resident have any skin problems? No, Name of nurse notified- Not applicable A document for certified nursing assistants titled, Daily Charting dated 04/22/26 documented in part, Description- bathing support provided, Time – 7 AM -3:30 PM, Status-One-person physical assist, Guidance-check resident skin for rashes, redness, wounds, bruises, if any problems noted, you must notify the nurse, Description-Does the resident have any skin problems? No, Name of nurse notified- Not applicable. An April 2026 Treatment Administration Record revealed that nurses signed their initials for 10 AM on 04/21 and 04/22, indicating that they provided wound care for the resident's sacral wound on those dates. A Situation, Background, Appearance, Review document dated 04/22/26 at 5:30 PM documented in part, Skin evaluation – no changes observed. A Skin Evaluation Form dated 04/23/26 at 7:25 PM documented in part, Left Buttocks DTI (Deep Tissue Injury) unstageable 30% skin, 20% slough, 50% dermis. Treatment-Cleanse with normal saline, pat dry, apply sliver alginate, [and] cover with optifoam. Occurred where-[NAME] Manor Nursing and Rehab Center [Ascension Health]. Size: length 8.0 cm, width 2.0 cm, depth not applicable. It should be noted that the facility's staff reclassified the resident's left buttock's DTI to an unstageable pressure ulcer when it opened on 04/23/26. Also, review of the resident's medical record lacked documented evidence of the resident's left buttock wound before the above-listed skin evaluation dated 04/23/26 at 7:25 PM. A Specialty Physician Initial Wound Evaluation & Management Summary dated 04/23/26 at 8:39 PM documented in part, Unstageable (Due to Necrosis) of the left buttocks full thickness, pressure, unstageable necrosis, noted to present on admission per staff, wound size length-8cm (centimeters) X width – 2 cm X depth – not measurable, exudate – moderate serous, slough – 20%, other variable tissue – 50%(Dermis).Procedure Notes- The wound was cleansed.then with clean surgical technique, 15 blade was used to surgically excise(to surgically remove).devitalized(dead) tissue. During a wound care observation provided by Employee #15 (LPN/Wound Care Nurse) starting at 10:57 AM on 05/22/26, the dressing removed from the left buttocks pressure ulcer had a moderate amount dark color drainage, no smell was noted, size was approximately the size of a quarter, wound bed covered with dark and yellow tissue, and no redness, swelling, or maceration was noted on the periwound. During a face-to-face interview at approximately 12 PM on 05/22/26, Employee #15 stated that she was recently returning from vacation for a month. She said that she was on vacation when the resident was admitted and when the resident's wounds were discovered by staff. Additionally, the employee reviewed the resident's wound care notes and stated that, according to the notes, the resident's left buttocks unstageable pressure was first observed by staff on 04/23/26. During a telephone interview starting at 12:13 PM on 05/27/26, Employee #14 (Wound Care Physician) stated that 04/23/26 was the first time he assessed the resident's wounds. The physician stated that the facility staff informed him that the resident was admitted with three wounds (post-surgical back wound, unstageable sacral pressure ulcer, and left buttocks pressure ulcer). The physician said that during his visit, he debrided both unstageable pressure ulcers. During a face-to-face interview at 10:13 AM on 05/29/26, Employee #12 [RN] stated that she and Employee #13 (RN) admitted Resident #150 to the facility on [DATE]. The employee said that when the resident was admitted , her skin in the sacral and groin area was dry, red, and intact. Additionally, the resident had a surgical wound on her back with intact staples. During a face-to-face interview at approximately 11:45 AM on 05/29/26, Employee # 13 (RN) stated that the resident was admitted to the facility without any open areas. The employee said that she documented in error that the resident had a Stage 2 sacral[pressure]ulcer on the Skin Evaluation form dated 04/09/26. Additionally, the employee stated that she observed the resident had a Stage 1 (pressure injury) area of redness in her sacral area. During a face-to-face interview at approximately 3:30 PM on 05/29/26, Employee #2 (DON) stated that staff did not make her aware of the resident's left buttocks unstageable wound. The employee stated it is the protocol that staff make her aware of wounds because they will determine if they do a root cause analysis of the wound. 2. Review of Resident #87 admission Progress notes created 4/11/2026 16:36 show Resident #87 was admitted [DATE] to the unit from home via private transportation. Resident alert and oriented to self and person, disoriented to time and place, consistent with history of dementia, no acute distress noted upon arrival. Comprehensive head to toe assessment completed. Skin assessment performed, skin noted to be intact. No pressure injuries noted on admission. Resident ambulates with assistance, gait observe to be unsteady . Nurse Practitioner assessment note included in part: created 04/11/2026 at17:22 showed admitted from home with diagnoses include Diabetes Mellitus type 2 Hypertension [AGE] years old female .Head to toe skin assessment was done, no open areas noted, resident noted with pink scar tissue on the coccyx areas, multiple strikes scars to the bilateral lower extremities and pink scar tissue on the right lateral ankle area. Resident has short thick and brittle toe nails. Care Plan dated 4/11/2026 showed Category16 Pressure Ulcers/Prevention: (Resident #87 is at risk Risk for pressure ulcers and other skin related injuries will maintain skin integrity without new skin related injuries over the next few. Next review period of rating scale to be completed key bed linens wrinkle free and do not use excess pads observe skin for redness and break down during routine care use pressure relieving devices cushion on wheelchair and of of ears as indicated follow community skin care protocol treatments as indicated seized physicians order sheet pressure reducing mattress on bed OK admitted to the unit from home . comprehensive head to toe assessment completed. Skin assessment performed. Skin noted to be intact. No pressure injuries noted on admission. Careplan dated 4/13/26 showed Category 6 Incontinence: altered elimination due to incontinence of bowel and bladder: Skin will remain clean, dry and free of breakdown related to incontinence: need perineal cleansing and apply protective skin barrier after each incontinent episode, provide adult incontinent products and monitor for incontinence: assess and report signs of impaired skin integrity or break down. Nursing Progress Note created 4/27/26 10:42AM showed [Resident #87] is alert, breakfast served, appetite good consume 100% fluid intake 240cc, shower provide skin intact up in wheelchair. participate unit activities at living room drawing picture and socialized with other resident vital signs are T 97.2, R18, P90, BP145/81, sat 98 no abnormal behavior noted. Nursing Progress Note created 4/28/26 2:51PM showed Change in Condition: [Resident #87] alert during the ADL (activity of daily) care provided, resident observed with sacrum opening, this writer made aware nurse notify measure 0.2cm x 0.3cm no drainage. NP made aware new order zinc oxide twice a day cover with dressing, wound consult, family representative (name) notified. Careplan dated 4/29/2026 Category16 showed Risk for pressure ulcers and other skin related injuries, maintain skin integrity without new skin related injuries, (Resident #87) has an open area on the sacrum r/t (related to) limited mobility and incontinence; sacral wound will resolve without complication by the next review dates. Provide treatment as ordered, Monitor for pain and s/s of infection and notify MD (medical doctor), Continue all other interventions for skin care. Progress Note dated 4/29/2026 2:43PM showed Nutrition Note: RD (registered dietitian) notified of sacral skin opening (0.2 cm x 0.3 cm per nursing note). Continues on regular diet, thin liquids with usual meal intake of 75-100% per nursing notes. Current intake is adequate to meet estimated needs. No nutrition interventions at this time. RD will continue to follow PRN and alter nutrition interventions as needed. Wound Evaluation and management Summary dated 4/30/2026 showed At the request of the referring Dr. [Doctor named] a thorough wound care assessment and evaluation was performed today Focus room exam Stage 3 pressure wound sacrum full thickness etiology and quality pressure stage 3 duration less than one day objective healing maintain healing earning potential is fair estimated time to heal is fair care goes this month prevent infection decrease wound area manage exudation approach close monitoring education and counseling offloading additional wounds detail and avoided unavoidable pressure wound all preventive measures in place dressing treatment plan primary dressing is alginate calcium with silver apply once daily and as needed if saturated soil or dislodged for 30 days secondary dressing is gauze island with BDR apply once daily and as needed if saturated soil or this large for 30 days. Wound treatment is zinc ointment 20% apply Q shift three times a day and that's needed it's saturated soil or dislodged for 30 days Medication Flow sheet showed the dates with the type of wound treatments provided follows: Start date 4/28/26 – End date 5/1/26 Desitin Daily Defense (zinc Oxide) apply topically two for opening sacrum time twice a day Continue 5/02/26 – open end date apply topically every shift to periwound on sacrum for skin care Treatments flow sheet showed the dates with the type of wound treatments provided follows: Start date 5/8/26 – End date 5/14/26 Alginate Calcium, Cleanse sacrum wound with NS, pat dry, and apply alginate calcium w/silver, then cover with Optifoam dressing once a day (7AM -3PM). Start date 5/15/26 – End date 5/15/26 Medihoney /Alginate Calcium, Cleanse sacral wound with NS,, pat dry, and apply medihoney alginate calcium w/silver, then cover with Optifoam dressing once a day (7AM -3PM). Start date 5/16/26 – Open end: Alginate Calcium, Cleanse sacrum wound with NS, pat dry, and apply alginate calcium w/silver, then cover with Optifoam dressing once a day (7AM -3PM). 5/22/2026 1:52pm Weight/wound note: Resident is triggering for sig weight gain of +9.7 lbs (7.5%) within 1 month following reweight .RD noted weight variance (lbs), (5/22) 137.5, (5/13): 141.8, (5/5): 139.4, (5/2): 129, (5/2): 142.1, (4/30): 128, (4/11 -admission): 127.8. No weight history/UBW on admission paperwork. BMI is 26.9, overweight, however within ideal range for age. Resident continues on regular diet (seafood allergy) with usual intake of 51-75% of meals. Resident with Stage 3 sacral PI [pressure injury]. Recommend addition of 30 mL liquid protein to support wound healing. Recommend monitoring weekly weights x3 weeks. RD will continue to follow. Observation made on 6/1/26 10:50 during wound care, the Sacrum wound, size of 0.8x0.4, has pink edges, no drainage and small amount of yellow (slough) in the middle. Interview was conducted on 6/1/26 10:53AM with the wound nurse. She stated Resident had no wound on admission, wound was found 4/29/26, Stage #3 wound, the measurement on Thursday was 0.8x0.4, daily dressing change completed, treatment is Alginate silver and cover with Opti form pads. Wound healing is in progress. Interview on 6/1/26 10:56 concerning comfort level with Resident#87, she denies pain at wound site. Told surveyor it was ok to come in and see the wound /wound care. A interview with the Director of nursing was conducted on 6/15/2026 at 3pm concerning the initial observation of Resident#87's altered skin at an advanced stage (sacrum wound initially identified at Stage #3).

Number of residents sampled: Number of residents cited: Based on record review and interview, for two (2) of 53 sampled residents, the facility staff failed to ensure: (1) Resident #150's record contained accurate documentation related to the staging of her wound. (2) Resident #179's record contained accurate documentation of skin sheets. (Residents #150 and #179)The findings included: 1. Resident #150 was admitted to the facility on [DATE] with multiple diagnoses including Fracture of First Lumbar Vertebra, Abnormalities of Gait Mobility, Generalized Muscle Weakness, Severe Protein-Calorie Malnutrition, and Need for Assistance with Personal Care.The policy Procedure: Pressure Injury Assessment/Treatment with a review date of 01/26 documented in part, There are four stages of pressure injury.Stage 1 -skin remains intact at this stage. Intact skin with a localized area of non-bleachable erythema.Stage 2-partial thickness loss of skin with exposed dermis. The wound bed is pink or red, moist.An admission nursing progress note dated 04/09/26 at 6:06 PM documented in part, Resident is alert, oriented and verbally responsive. Skin is warm to touch, redness and dryness noted towards perineal, right groin and sacral area. A skin evaluation form dated 04/09/26 at 10:55 PM documented in part, Sacral Ulcer with redness/Moisture Acquired Skin Damage. Treatment: Cleanse the sacral area with normal saline; apply Z-Guard after incontinent care. Occurred where - [local hospital's name]. Stage-2.During a face-to-face interview at 11:45 AM on 05/29/26, Employee #13 (RN) stated that she was one of the nurses who admitted the resident on 04/09/26. The employee said that she documented in error that the resident had a Stage 2 sacral pressure ulcer. Additionally, the employee stated that on admission [DATE]) the resident had a Stage 1 sacral injury. The skin was red with no open areas. 2. Resident #179 was admitted to the facility on [DATE] with multiple diagnoses including Dementia, Acute Respiratory Distress, and Need for Assistance with Personal Care.A State Survey Agency Complaint Intake #2732976 dated 01/30/26 documented in part, In August 2024, Ms. [NAME] reports that a letter was submitted to the facility regarding a bedsore. The bedsore reportedly remained present, caused discomfort, and the resident was not receiving adequate assistance. During a review of the resident's medical record on 05/29/26 at approximately 11 AM, the record lacked documented evidence of shower sheets for August 2024. At the time of the record review, Employee #23 (Unit Manager/RN) stated that she would check for the records in the filing closet. The employee also stated that the facility's protocol requires the nurse and CNA to observe the resident's skin from head to toe for skin integrity issues/concerns and document the findings on the CNA Bath and Shower Documentation Sheet. At approximately 1 PM on 05/29/26, Employee #26 (RN) provided the surveyor with CNA Bath and Shower Documentation Sheets dated 08/14/24, 08/17/24, 08/21/24, 08/24/24, 08/28/24, and 08/31/24. Review of the shower sheets revealed the staff did not document any concerns with Resident #179's skin. The employee stated that she could not find the original shower sheets, so she looked at the staff schedule for those days and had staff who worked to re-create them. The employee said that she could not verify if the information documented about Resident #179's skin assessment was accurate because she did not work for the facility during that time. During a face-to-face interview at approximately 1:30 PM, Employee #27 (CNA) who signed her name on the shower sheets for 08/14/26, 08/17/26, 08/21/26, 08/28/26, and 08/31/26 stated that she was asked to complete the sheets today (05/29/26). The employee said that she could not verify if the information was accurate. During a face-to-face interview at approximately 2 PM on 05/29/26, Employee #2 stated that the employees should not have re-created the shower sheets.

Number of residents sampled: Number of residents cited: Based on record review and staff interview, the facility's staff failed to ensure that a resident's PASSAR II referral was completed within 30 days of admission for one (1) of 53 sampled residents. (Resident #150). The findings included:Resident #150 was admitted to the facility on [DATE] with multiple diagnoses including Unspecified Psychosis, Anxiety Disorder, and Major Depressive Disorder.A review of the resident's medical record revealed a PASSAR I form dated 04/09/26 that failed to capture that the resident had a history of a serious mental illness. Additionally, the form was incomplete and failed to document if a referral for a PASSAR II was necessary. A care plan dated 04/09/26 documented, Problem- Level II PASARR is not needed. Goal-[Resident's Approach (Intervention)-Level II PASSAR is not needed.During a face-to-face interview at approximately 12PM on 06/01/26, Employee #4 (Director of Social Work) stated that the PASSAR I form dated 04/09/26 was completed incorrectly. She would complete another PASSAR I on 06/01/26 [52 days after admission] and submit a referral for a PASSAR II because of the resident's mental health diagnoses.

Based on observation, record review, and staff interview, for one (1) of 53 sampled residents, the facility staff failed to evaluate a Resident for occupational therapy services per the physician's order. Residents #146.The findings included: Resident #146 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Dementia, Chronic Kidney Disease Stage 4, Chronic Embolism and Thrombosis, Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath, and Retention of Urine, Localized Edema, and Unsteadiness on Feet. On 05/13/26, the State agency and the facility received a Complaint (3012416) via email from Resident #146's family member and the Resident's legal guardian, which documented in part: Since May 4th, my mother has made multiple requests for a return call from the [Name of Facility's Medical Team] .our request to speak directly with a physician or nurse practitioner has gone unanswered . An email response to the State agency dated 05/15/26 from the Facility's Administrator documented: .Please see updates below in reference to concerns listed above.DON (Director of Nursing) met with daughter.Spoke with NP who will have the attending see the resident on Friday, May 15th. Order placed and communicated with therapy for OT to eval [evaluate] entry for ability to feed herself. Family was able to speak with the NP. A review of Resident #146's medical record revealed: A quarterly Minimum Data Set (MDS) assessment dated [DATE] that documented that Resident #146: had a Brief Interview for Mental Status (BIMS) summary score of, 3, indicating that the resident had severely impaired cognition; required maximal assistance to from facility staff for eating, oral hygiene, upper body dressing, and applying footwear; was dependent on facility staff for toileting, bathing, and personal hygiene; had an indwelling urinary catheter; was frequently incontinent for bowel movements, and had received an anticoagulant within the past seven days of the assessment.A physician's order dated 05/14/26 that directed: OT (Occupational Therapy) to eval (evaluate) for decreased ability to feed self once a day, prn (as needed). A nursing progress note dated 05/18/2026 at 12:09 PM that documented: Writer received a call and an Email from [Resident #146's Legal Guardian] requesting an in-person family care meeting on 05/14/26 with the current attending physician, Nurse Practitioner, Clinical Nursing Leader for the fourth floor, and assigned social worker. The meeting was held on 5/14/26 per [Resident #146's Legal Guardian]'s request. concerns included lack of communication with the medical team, resident's ability to feed herself.order was placed for OT to evaluate and treat resident for ability to feed herself, and resident. Further review of Resident #146's medical record showed no documented evidence that occupational therapy evaluated Resident #146's ability to feed herself after conducting the family meeting held on 05/14/26, and per the physician's order on 05/14/26. During a face-to-face interview on 05/29/2026 at 10:34 AM, Employee #1 (Administrator) stated that she had a paper trail to show that the legal guardian's concerns for Resident 3146 were addressed. She added that the NP (Nurse Practitioner) and OT (Occupational Therapy) met with the family. During a face-to-face interview with Employee #2 (Director of Nursing/DON) stated that she sent the following email to OT on 05-14-26 at 2:30 PM: Good Afternoon, Please have OT evaluate her period. Apparently, she can feed herself on some days and on other days she cannot. On 04-14-26 at 2:57 PM. Employee #24 (Director of Rehabilitation Services) sent the following email correspondence to Employee #2 /DON: Ok, no problem. We'll start the process tomorrow. During a face-to-face interview on 6/15/26 at 4:22 PM, Employee #24 stated, The Resident was on my list of residents to be evaluated for OT on 5/23/26. I had to prioritize that list with new admissions always first to be evaluated. Resident #146 got pushed down on the list. I did not let her family, the Administrator, or the DON know that. The Employee then acknowledged the finding.

Based on observations and staff interviews, it was determined that the facility staff failed to wash and sanitize chinaware plates and silverware properly; and failed to ensure that supplements were not stored beyond the 'use by' date for for 17 of 24 Ensure supplements observed expired. The findings included: 1. During an observation of the dishwashing process in the main kitchen at approximately 4 PM on 06/15/26, it was revealed that six (6) of 21 chinaware plates, three (3) of 3 forks, three (3) of 25 spoons, and one (1) of 10 knives were not properly sanitized as evidenced by food particles remaining on the eating surface of the previously mentioned chinaware plates and eating utensils after they had been washed and sanitized. During a face-to-face interview at approximately 4:30 PM on 06/15/28, Employee #11 (Dietary Manager) stated that the staff would rewash and sanitize the plates and eating utensils. 2. During an observation conducted on 05/28/26 at approximately 12:40 PM of the Second-Floor medication storage room, it revealed an opened case of Ensure supplement drinks with a use by date of 05/01/2026 and only 17 of 24 – eight (8) fluid ounce supplement drinks remaining. It should be noted that seven (7) – eight (8) fluid ounce supplement drinks were unaccounted for. During a face-to-face interview conducted on 05/28/26 at approximately 12:45 PM with Employee #5 (Registered Nurse, Unit Manager), she acknowledged the findings.

Number of residents sampled: Number of residents cited: Based on record review and staff interviews for one (1) of 53 sampled residents, it was determined that the facility staff failed to notify the resident and resident representative of the discharge in writing and in a manner they understood at least 30 days in advance of the discharge. Resident #195. The findings included: A facility policy titled 'Transfer or Discharge, Preparing a Resident for' with a next review date of 01/2027 documented, in part: When a resident is scheduled for transfer or discharge, the social worker, or designee, will notify nursing services of the transfer or discharge so that appropriate procedures can be implemented and This plan will be reviewed with the resident, and/or his her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility and Nursing services is responsible for: 1. Obtaining orders for discharge. Resident #195 was admitted to the facility on [DATE] with multiple diagnoses that included: Arthritis, Osteoporosis, Deep Vein Thrombosis, Urinary Tract Infection and History of Falls. A review of a complaint intake [#3028339] received by the State Agency on 05/22/26 at 1:33 PM documented, in part: .states that [Facility name] is performing an unsafe discharge and that a discharge meeting was never held. During a face-to-face interview conducted on 06/09/26 at approximately 1:57 PM with Employee #3 (Assistant Director of Nursing) she stated, in part: The son, I saw him on the day of discharge [05/19/26] and the staff didn't know about the discharge because it was in the afternoon I was making rounds and he said he needed a wheelchair to take his mother home. I asked why and he said she [Resident #195] was discharged . I asked who told you your mom was discharged and he said that the Social Worker did the discharge in the patient's room. During the morning meeting, the next day, I brought it up as a concern because of the communication gap that the nursing staff did not know that the resident was being discharged from the facility. She [Social Worker's name] didn't follow the due process for discharge . to list the name of residents to be discharged ; call the Doctor or Nurse Practitioner to get the discharge orders. We [are] supposed to get an order [discharge order] in advance. The nurses didn't know about the discharge; if the resident had her own wheelchair he could've taken her without anybody knowing because we didn't know. I also told the Director of Nursing. After that incident we now have a [discharge] process with Social Services. It should be noted that there was no documented evidence of a physician's discharge order in the resident's record.During a face-to-face interview conducted on 06/10/26 at approximately 09:30 AM with Employee #4 (Social Services Manager) she acknowledged the findings and stated, in part: The former [Social Worker's name], she did the admission and care plan meetings, she was new so she hadn't done a care plan so not really sure if information was communicated to the son and the resident about what the discharge plan was, or any barriers to discharge and I did the discharge planning meeting with the [resident's] son, [physical therapist name] and the resident on the day the resident was discharged [05/19/26]. The Son had reached out to the Ombudsman, and the Ombudsman was asking for discharge planning meeting after the resident's son had contacted them. After I left the room, I don't [didn't] know what happened afterwards. For the discharge folder the process is there's a bin on the unit for all discharges, I pulled the folder from the bin, but I don't recall if I told anyone. The discharge planning meeting should include the Social Worker, Rehab department, and other departments with the resident and family. If other departments aren't available, it's not a complete discharge or IDT (interdisciplinary team) meeting.

Based on observation record review and staff interview, for two (2) of 53 sampled residents, the facility staff failed to fully implement the care plan interventions for a Resident who had an unwitnessed fall and failed to develop a care plan to manage an unstageable pressure ulcer for one resident. Residents #146 and #150. 1. Resident #150 was admitted to the facility on [DATE] with multiple diagnoses including Fracture of First Lumbar Vertebra, Abnormalities of Gait Mobility, Generalized Muscle Weakness, Severe Protein-Calorie Malnutrition, and Need for Assistance with Personal Care. A Skin Evaluation Form dated 04/23/26 at 7:25 PM documented in part, Left Buttocks DTI (Deep Tissue Injury) unstageable 30% skin, 20% slough, 50% dermis. Treatment-Cleanse with normal saline, pat dry, apply silver alginate, [and] cover with Optifoam. Occurred where: [NAME] Manor Nursing and Rehab Center [Ascension Health]. Size: length 8.0 cm, width 2.0 cm, depth not applicable. A physician order dated 04/24/26 instructed in part, Cleanse left buttocks DTI with normal saline, pat dry, apply silver alginate, cover with Optifoam one time. During a wound care observation provided by Employee #15 (LPN/Wound Care Nurse) starting at 10:57 AM on 05/22/26, the dressing removed from the left buttocks pressure ulcer had a moderate amount dark color drainage, no smell was noted, size was approximately the size of a quarter, wound bed covered with dark and yellow tissue, and no redness, swelling, or maceration was noted on the peri wound. During a face-to-face interview starting at approximately 3 PM on 05/22/26, Employee #2 (DON) stated that staff should've developed a care plan for the resident's left buttocks pressure ulcer. 2. Resident #146 was admitted to the facility on [DATE] with diagnoses that included: Unspecified Dementia, Chronic Kidney Disease Stage 4, Chronic Embolism and Thrombosis, Chronic Obstructive Pulmonary Disease (COPD), Shortness of Breath, Retention of Urine, Localized Edema, and Unsteadiness on Feet. On 05/28/2026 at 11:21 AM during the facility's recertification survey, the State Surveyor was made aware that Resident #146 had an unwitnessed fall on 06/27/26 per Complaint #3012416 that was emailed to the State agency on 05/28/26. The following post-fall, the following observations of Resident #146 were made: On 05/28/26 at 11:54 AM, Resident #146 was observed asleep in bed, lying supine. The Resident was receiving oxygen (2 liters) via nasal cannula. The Resident was resting on a larger bed (bariatric bed). There was one (1) floor mat on the left side of the bed , and no floor mat on the right side of the Resident's bed. The surveyor observed no other floor mat in the Resident's room. On 05/28/26 at 1:22 PM, during the observation, Employee #20 (Certified Nurse's Assistant/ (CNA) and Employee #19 (Licensed Practical Nurse/LPN) the assigned nurse entered Resident #146's room to change the Resident. There was one floor mat on the left side of the bed. Employee #19 moved the floor mat away from the left side of the Resident's bed to avoid stepping on the mat before assisting the Employee #20 with repositioning the Resident and changing the Resident's pants. The surveyor observed no other floor mat in the Resident's room. On 06//05/26 at 2:15 PM, Resident #146 was observed asleep in bed, lying supine. There was one floor mat on the left side of the bed and no floor mat on the right side of the Resident's bed. The surveyor observed no other floor mat in the Resident's room. A review of Resident #146's medical record revealed: A quarterly Minimum Data Set (MDS) assessment dated [DATE] that documented that Resident #146: had a Brief Interview for Mental Status (BIMS) summary score of, 3, indicating that the resident had severely impaired cognition; required maximal assistance to from facility staff for eating, oral hygiene, upper body dressing, and applying footwear; was dependent on facility staff for toileting, bathing, and personal hygiene; had an indwelling urinary catheter; was frequently incontinent for bowel movements, and had received an anticoagulant within the past seven days of the assessment. A nursing progress note dated 05/27/2026 09:58 AM, which documented: CNA reported to this nurse at 5:30 AM. The resident was observed on the floor. The resident was alert and responsive nursing supervisor was notified and assessed the resident. No apparent injury noted. Assisted the resident back to bed; no pain noted after the fall, neuro check obtained. Physician's orders dated 05/27/26 at 1:14 PM that directed: 1) Fall: Monitor status for 72 hours for bruising, change in mental status/condition, pain, or other injuries related to the fall. Every Shift. 2) Fall: Physical Therapy Consult x1, Once - One Time 08:00 AM - 01:00 AM, 3) Fall: With Suspected head trauma - Neuro checks Q15 minutes x 4, then Q1 hour x2, then Q2 hours x2, then Q4 hours x2, then Q shift x3 [05:45 AM, 06:00 AM, 06:15 AM, 06:45 AM, 07:45 AM, 08:45 AM, 10:45 AM, 12:45 PM, 04:45 PM, and 08:45 PM]. A care plan initiated on 05/27/26 that documented: Category: Falls [Resident #146] had a fall; Goal: [Resident #146] will not have a fall with injury through the next review date x 90 days; Approaches: Provide resident with a bariatric bed to allow for more space for movement; Fall Mat at both sides of the bed while resident is in bed for safety; PT/OT s/p fall Neurological Assessment x 72 hrs (hours) . A review of the neurological assessments (neuro-checks) on 05/27/26 from 05:45 to 08:59 AM showed no documented evidence that vital signs were taken and progress notes were written (as directed by the instructions of the assessment) and showed no documented evidence of a date or signature by a nurse to indicate that the neuro- check assessment was done and completed. A review of the Resident's treatment administration record for June 2026 showed no dates or times to indicate that the nurses were performing neuro-checks on Resident #146 per the physician's order. A nursing progress note dated 05/27/2026 at 04:27 PM that documented: Resident is alert oriented and verbally responsive, and in no respiratory distress or SOB (shortness of breath) noted at this time .S/P f(status post) all no injuries noted at this time, resident denied any pain when asked. Safety precautions were maintained, the call button was within reach, and the resident was encouraged to call for help at the time. Bed in the lowest position, floor mat in place. Further review of Resident #146's medical record showed no documented evidence that facility staff implemented the post-fall care plan approaches/interventions, which included 72-hour neuro-checks after the Resident's fall on 05/28/26, or floor mat placement on both sides of the Resident's bed. During a face-to-face interview on 05/28/26 at 3:03 PM, when asked if the nurses were performing neuro-checks on Resident #146, Employee #2 (Director of Nursing /DON) stated that she and the nurses were still learning the new electronic health record (eHR) system. She further stated that once the order for neuro-checks was entered onto the Resident's electronic health record, she thought the neuro-check times would automatically populate on the Resident's TAR. When reviewing the neuro-check assessments in the Resident's eHR, she stated that she knew the nurses were doing them per the physician's order, but she had no explanation for why the neuro-checks were not completed in the Resident's eHR, or why the nurses were not signing and dating them. During a telephone interview on 06/15/26 at 1:33 PM, Employee #21 (CNA) stated, I was not assigned to the Resident for care that day, but as I was passing by the Resident's room, I noticed Resident #146 was on the floor. She was facing the door beside her bed on the floor. We put her in bed. When I saw her the next day, there was a floor mat only on the left side of the bed. During a telephone interview on 06/15/26 at 2:53 PM, Employee #22 (LPN), stated that she was assigned to Resident #146 when the CNA reported that the Resident was on the floor. The Employee further stated that [Name of Resident#146] was assisted back to bed, and an assessment was done. The nurses then started neuro-checks and documented them in the Resident's chart. They moved the Resident to another room across the hall. When I observed the Resident, her bed had 1/2 headrails up on both sides, and there was one floor mat on the side of her bed facing the door. During a face-to-face interview on 06/05/26 at 2:18 PM with Employee #23 (Registered Nurse/Unit Manager), when asked about the floor mats, she stated that during her rounds, she checked to make sure the Resident had floor mats on both sides of the bed. She then added that sometimes, before feeding or providing care for the Resident. The CNAs will remove the floor mats, and sometimes they forget to put them back. When the surveyor discussed her post fall observations of the Resident's bed with only one floor mat, the Employee acknowledged the finding and made no further comment

Number of residents sampled: Number of residents cited: Based on record review, staff interview, and resident interview, the facility's staff failed to follow up with a resident's physician for cataract surgery for one (1) of 53 residents.(Resident #157)The findings included:Resident #157 was admitted to the facility on [DATE] with multiple diagnoses including Cataracts of Right and Left Eye, Dry Eyes, and Hypertension Retinopathy.A progress note dated 08/25/25 at 4:01 PM documented in part, Resident came back from her appointment with Dr. [NAME]. She was seen for a chief complaint of follow-up ocular hypertension involving the left eye and right. The symptoms are associated with blurred vision and are mild in severity. [Physician's name] recommended that resident should go to [local hospital] Ophthalmology for cataract evaluation.A progress note dated 09/29/25 at 12:55 PM documented in part, Resident left.facility for cataract evaluation.[Physician's name] recommended eye surgery at [hospital's name].A care plan meeting progress note dated 10/30/26 at 4:01 PM documented in part, Resident has an upcoming cataract surgery, all recommended clearances are complete, awaiting call back from eye doctor for available date for resident's eye surgery.During a face-to-face interview at 11:17 AM on 06/08/25, Employee #17 (ADON) stated that the resident completed all pre-op tests for cataract surgery. The employee also said it was an oversight that staff did not call the physician to schedule the surgery. Additionally, the employee stated that staff had made an appointment for 07/17/26 for the resident to start the process again.

Based on observations, record reviews, resident and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to ensure that adequate supervision was provided, in accordance with Resident #1's person-centered plan of care, to prevent her from eloping from a safe area, without authorization. Subsequently, Resident #1 eloped from the secure Memory Care unit on 02/21/26 at 11:45 AM. During this survey, an Immediate Jeopardy (IJ-J) was identified at 42 CFR 483.25, Quality of Care, F689, Free of Accident Hazards/Supervision/Devices on 03/18/26 at 1:12 PM. The facility's Administrator submitted an abatement plan to the Survey Team that was accepted on 03/18/26 at 5:27 PM. The Survey Team verified implementation of the abatement plan while onsite and the immediacy was lifted on 03/24/26 at 3:38 PM. After removal of the immediacy, the deficient practice was lowered to a scope and severity level of D.The findings included: Review of the facility's Elopement and Wandering Residents last reviewed in January 2026 documented in part:- This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk.- Elopement occurs when a resident leaves the premises or a safe area without authorization. - Alarms are not a replacement for necessary supervision. - Adequate supervision will be provided to help prevent accidents and elopements. Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included Dementia, Congestive Heart Failure, Hypertension and Age Related Macular Degeneration. A physician's order dated 06/04/25 that directed, Behavior - every shift, monitor resident for behavioral related to. elopement, impaired adjustment. Physician's order dated 07/08/25 directed, Code alert (wander guard bracelet) for safety monitoring, every shift. Check for placement every shift for elopement; Elopement alert: code alert, every shift, check functioning of code alert for elopement. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 10 indicating moderately impaired cognitive status; wandering behavior not exhibited; no functional limitations in range of motion; used a walker mobility device; and wandering/elopement device was used daily. 01/09/26 at 11:37 PM Elopement Risk Screening: Score 27 - assume resident is at risk for elopement. A care plan focus area revised on 02/11/26: [Resident #1] is at risk for elopement related to poor safety awareness. Interventions: follow community elopement evaluation and monitoring process. A care plan focus area revised on 02/11/26: [Resident #1] had impaired behavior related to refusing care and medications. Interventions included: Staff to replace roam alert bracelet (wander guard) as soon as it is known the resident has removed her bracelet; nursing to check and know the whereabouts of resident at all times. A care plan focus area revised on 02/11/26: [Resident #1] hoovers around the main exit door with her friend waiting for someone to allow them to leave. Interventions: keep [Resident #1] safe on the locked unit; [Resident #1] is on high alert for elopement, all must be aware of her high elopement status. 02/20/26: A maintenance logbook documentation of the wander guard system showed that all the Resident Monitoring Systems (wander guard systems) were checked, and all marked as pass. 02/21/26 at 11:00 AM Safety Checklist:- Employee #6 (Certified Nurse Aide/CNA) documented 01 meaning that the resident was observed in her room. Video recording from 02/21/26:11:40 AM, Employee #3 (Food Service Manager) enters the 1st first floor pantry through the doors located right before entry/exit double doors of the Memory Care unit and then leaves the pantry door wide open.11:44 AM, Resident #1 walks up to the dining room doors, located closest to the main entry/exit double doors of the unit, and hoovers there as Employee #4 (Food Pantry Worker) is inside the pantry. At 11:44 AM and 27 seconds, Employee #4 exits the pantry through the other pantry entry/exit door that leads to the dining room At 11:44 AM and 35 seconds, Resident #1 opens the dining room doors and walking inside.At 11:45 and 32 seconds, Resident #1 walks into the pantry, through the dining room entry/exit doors, pushing her rolling walker and walks out of the still open pantry door located outside of the Memory Care unit, without staff knowledge. At 11:46 AM, Resident #1 walks past two security officers sitting in the main lobby, without a walker, holding a jacket and a bag. It should be noted that Employee #5 (Security Officer) did get up and follow the resident as she walked outside the facility's main entry/exit doors. A Facility Reported Incident (FRI), intake #2785082, submitted to the State Agency on 02/21/26 at 2:07 PM documented in part:I [Employee #8, Nurse Supervisor] was called by security to come outside to identify a person outside at the door with a bag around 11:48 AM. Once outside, I noticed the person was the resident from the first floor (Memory Care unit), [Resident #1]. I called nurses from the first floor who came out to help me with wheelchair to transfer the resident who was continuing to resist to come in. The resident was brought safely back to the first floor. Head-to-toe assessment done. Review of the security camera showed that the resident exited the floor by the kitchen door. Per the staff, the resident does not wear wander guard. She always cuts it off. That was the reason. The alarm did not go off. A new one was put on the resident at this time. During a face-to-face interview on 03/16/26 at 9:00 AM, Resident #1 stated, I wanted to get some air. There's no circulation in this place. I knew I could get out through the pantry because there wasn't anyone there. When I was walking out, no one tried to stop me until I got outside. I had someone coming to get me but then I called and told them don't come anymore. During a face-to-face interview on 03/16/26 at 2:00 PM, Employee #10 (Licensed Practical Nurse/LPN) stated, I was on shift that day (02/21/26) but was not the assigned nurse. I remember I had put a wander guard bracelet on her (Resident #1) leg, I cannot remember which one. The bracelet was functioning just fine; I used the machine to test it. After the incident, we discovered that the resident had a pair of scissors that she used to cut the bracelet off. We found the scissors and the cut [wander guard] bracelet, that were wrapped in paper towels, inside her pocketbook. We are not sure where she got the scissors from, but we took them away. During a face-to-face interview on 03/16/26 at 2:36 PM, Employee #2 (Director of Nursing/DON), it was brought to the employee's attention that Resident #1 had an intervention of nursing to check and know the whereabouts of resident at all times in her refusal of care/treatment care plan. When asked what does nursing to check and know the whereabouts of resident at all times mean, Employee #2 stated, Staff were doing every one-hour checks on the resident's location. When asked would at all times include the times in between the every one-hour safety checks, Employee #2 stated. I can't explain what 'at all times' means. I know staff frequently had eyes on her. The evidence showed that facility staff failed to check and know the whereabouts of Resident #1 at all times and subsequently, the resident was able to elope from the secured Memory Care unit on 02/21/26 at 11:45 AM. Due to these failures, an Immediate Jeopardy (IJ-J) was identified on 03/18/26 at 1:12 PM. An approved abatement plan submitted to the State Agency on 03/18/26 at 5:27 PM entailed: 1. Corrective action for residents noted to have been affected by the deficient practice. Resident #1 is a resident located on the 1st floor memory care unit and has been deemed an elopement risk. On 2/21/2026, the resident was observed outside the facility, unsupervised, by the security officer. The security officer alerted the supervisor. Resident was brought back into the facility by the Supervisor and other first floor staff. Upon re-entering the first floor, resident had a head to toe assessment conducted by her charge nurse and supervisor and no abnormalities were noted. Resident #1's care plan stated that nursing will check and know the whereabouts of the resident at all times. Care plan has been revised, as of 3/18/2026, to reflect that resident will be monitored for her location and whereabouts every 30mins, which is an increase in monitoring as it relates to the facility's standard practices of monitoring for residents who are at risk for elopement every 1 hour. Resident is currently utilizing a wanderguard bracelet that will trigger both doors to the memory care unit and is no longer in possession of scissors to remove the bracelet. Upon discovery of the scissors, the charge nurse spoke with the resident's legal guardian and informed her of what occurred and that resident cannot have access to scissors. On February 21, 2026, education was provided to the dining staff by the Dining Manager regarding the pantry door from the dining room side on the importance of locking the door when no one is in the pantry. The pantry door that the resident was able to exit from was made inoperable so that no one could get in or out through that door by Maintenance. Although the pantry door that the resident was able to exit from was made inoperable, staff were able to get in or out the pantry though the door coming from the dining room, in case of an emergency. On March 2, 2026, both pantry doors in which the resident was able to enter and exit from had keypads placed on them and they are no longer able to open unless someone possesses the code. 2. How will the facility identify other residents having the potential to be affected by the same deficient practice? The facility will conduct a 100% audit of all residents who are at risk for elopement and ensure that they have behavior monitoring in place for wandering and/or exit seeking behaviors to be completed by 3/18/2026 All residents who are identified as an elopement risk and are exit seeking will have a care plan in place to reflect increased monitoring of every 30 minutes in an effort to ensure that frequent monitoring and supervision is in place for all residents who are at risk for elopement to be completed by 3/18/2026 All residents who are identified as an elopement risk will have a wanderguard put in place and an accompanying order to check for placement and functioning every shift to be completed by 3/18/2026 All residents who are identified as an elopement risk will have a care plan in place identifying their risk for elopement and person centered interventions that are to take place to prevent them from leaving unaccompanied to be completed by 3/18/2026 All residents who are identified as an elopement risk will have orders in place to check their wanderguards for placement and functioning every shift to be completed by 3/18/2026. 3. The measures the facility will take or systems the facility will alter to ensure that the problem will be corrected and will not recur. All employees will be re-educated on the importance of ensuring that all doors that shouldn't be left open and/or unlocked are properly closed and locked after entry/exit. Education will be provided by the Staffing Educator for the nursing staff and Department Heads will conduct the same education for their departments under the direction of the staffing educator. Education will begin immediately and is ongoing until 100% compliance is achieved. All charge nurses will be re-educated by the Staffing Educator on the process of checking the wanderguard for placement and functioning, including the method in which a wanderguard can be checked to ensure that it is functioning. Education will begin immediately and is ongoing until 100% compliance is achieved. All nursing staff will be educated by the Staffing Educator on the systematic change of increasing monitoring for residents who are at risk for elopement from every hour to every 30 minutes. Education will begin immediately and is ongoing until 100% compliance is achieved. All charge nurses will be educated by the Staffing Educator on the importance of documenting the location of the resident's wanderguard when checking for placement and functioning. Education will begin immediately and is ongoing until 100% compliance is achieved. The systematic change that will take place will include increasing monitoring for residents who are at risk for elopement and are exit seeking from every 1 hour to every 30 minutes. The change will take place on 3/18/2026. Completion Date: March 23, 2026. Cross Reference 22B DCMR Sec. 3210.4.

Based on record reviews and staff interviews, for one (1) of five (5) sampled residents, facility staff failed to ensure that they followed Resident #1's physician's order to not be assigned a male Certified Nursing Assistant/CNA.The findings included: Resident #1 was admitted to the facility on [DATE] with multiple diagnoses that included Dementia, Congestive Heart Failure, Hypertension and Age Related Macular Degeneration. Review of the resident's medical record revealed the following: A physician's order dated 07/28/24 that directed, Per resident request - every shift, no male CNA. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 10 indicating moderately impaired cognitive status; required supervision or touching assistance for personal hygiene. Review of the nursing assignment sheets and CNA documentation from 02/01/26 to 03/18/26 showed that a male CNA was assigned to and documented that they provided care for Resident #1 on the following dates and shifts:02/03/26, day and evening shift.02/04/26, day shift.02/05/26 and 02/06/26, day and evening shift.02/15/26 and 02/18/26, day shift.02/20/26, evening shift.02/21/26, day shift.03/03/26, 03/12/26, 03/14/26, and 03/15/26 evening shift. The evidence showed that Resident #1 was assigned a male CNA for a total of 15 shifts from 02/01/26 to 03/18/26. During a face-to-face interview on 03/19/26 at 9:40 AM, the findings were brought to the attention of Employee #12 (Assistant Director of Nursing/ADON) and Employee #13 (1st floor Unit Manager). The employees acknowledged the findings with Employee #13 stating, The staff know to not assign a male to [Resident #1]. I will talk to them and make sure that this doesn't happen again.

Based on medical record review and staff interviews, facility staff failed to ensure that a resident's food plan was followed and met her nutritional needs and preferences. This was evident for 1 of 3 sampled residents (#13). The findings included: A review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE] with multiple diagnoses that included: Status Post Reverse Arthroplasty of Left Shoulder, Asthma, Hypertension and Gastroesophageal Reflux Disease. A Physician's Order Reconciliation dated 11/02/25 documented, in part: Medicinal Allergies: Shellfish Derived. A History and Physical dated 11/03/25 documented in part, Allergies: Shellfish. 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 care plan dated 12/24/25 documented, in part: Nutritional Status: [Resident #13's name] has risk of altered nutrition status . Interventions: Provide diet as prescribed. Note shellfish allergy. Provide nourishment/supplement as ordered. Honor resident's food preferences. A review of the facility's dinner menu dated 12/26/25 documented, in part: Penne [pasta] with Spinach and Shrimp. A Complaint Intake [#2705985] submitted to the State Agency on 12/31/25 at 3:17 PM documented, in part: [Resident #13] has a documented shellfish allergy and the replacement food offered consisted of a peanut butter and jelly sandwich, a ham sandwich, and two bags of potato chips. This is not a nutritionally appropriate dinner for an elderly patient and Subsequent attempts to remedy the situation included three small pieces of chicken served in a plastic container, followed later at approximately 7:03 PM by a container of cold spinach. Due to the continued inadequacy of the response, I was forced to reorder a meal on [Resident #13's] behalf. During an observation by the State Surveyor conducted on 01/02/26 at approximately 09:00 AM, Resident #13's meal ticket was observed with the following documentation: Allergies: Shellfish Mollusks, Shellfish Crustaceans Allergen, Shellfish Allergen and a red circular sticker was affixed to the meal ticket. During a face-to-face interview conducted on 01/02/26 at approximately 2:15 PM, Employee #6 (Chef Manager) stated that, The food is plated by the pantry workers, the server/pantry worker places the resident's meal ticket on each individual tray. After the hot plate is plated with food it's given to residents in the dining area, or the food tray will go onto the hot box (silver food cart) then the nurse takes it and delivers to the residents. The nurse is the last to see the food tray before giving it to the resident. All food allergies are listed on the ticket. Pantry workers are supposed to read the ticket and only give food specific for the residents and nurses are supposed to read ticket and ensure food is correct before handing [it] to the resident. We stick to the policy. There's a red sticker [for patients with allergies] on the meal ticket and the server knows what food goes on the tray. I don't understand how it wasn't caught by the pantry worker when the food was plated, or by the nurse that served the food with shellfish. During a telephone interview conducted on 01/02/26 at approximately 2:30 PM, Employee #4 (Dietary Services/Pantry Worker) stated that, Yes, I worked that day [of the incident on 12/26/25]. My job is to put the food on the plate, and I put the food on the plate based on what the ticket said like regular or mechanical [diet]. On the old ticket you could see the allergies right away, but on the new ticket the allergies are listed much smaller. They (nursing staff) just asked me if she (Resident #13) could get something else [to eat for dinner], but the nurses never said it was because she had seafood on her plate. I think if I would've gotten better training, I probably wouldn't have made that mistake. During a face-to-face interview conducted on 01/02/26 at approximately 3:00 PM, Employee #5 (Certified Nursing Assistant) stated that, I came in [day of incident, 12/26/25] it was dinner time and I served her food. [Resident #13's] daughter and granddaughter were there when I got the tray, and the daughter assisted me and immediately the daughter looked at the food and said my mom is allergic to shrimp. I said [I was] sorry and took the food to the kitchen and gave it to the dietary staff. The dietary person went downstairs [to the kitchen] and got the resident something else [to eat] and took it to the resident. I think it was a sandwich but I'm not sure. What I usually do, I sit the tray on the table and then take the dome cover off [of the plate] to check what is on the ticket, but I didn't do it that day because the daughter assisted and she reached for the tray when I went in the room and grabbed it from me that's when she opened the cover and said she can't have this she is allergic. So, I took the tray back to the kitchen. I received the training about paying close attention to the ticket and the meal, but it's very visible on the meal ticket, you can see it [list of allergies]. During a telephone interview conducted on 01/02/26 at approximately 3:32 PM, Employee #3 (Dietary Director) acknowledged the findings and stated that, We are to provide meals per the policy. As far as the employee [who plated the food] it was an isolated incident; it was disappointing because we do so much training quarterly but because of the incident, we just did another training on 12/30/25 and 12/31/25; we took immediate action when it happened. The system is if it's not allowed or if not on the ticket, then the resident shouldn't get it [be served that food item]. The associate [Pantry Worker] who plated the food was counseled. During a face-to-face interview conducted on 01/05/26 at approximately 11:32 AM, Employee #2 (Director of Nursing) acknowledged the findings and stated that, When I was made aware, I followed up with nursing staff to go assess the resident and called daughter to get what happened. The staffing educator started the education with the nursing staff on 12/31/25 and the education is still ongoing. This issue was filed as a grievance rather than an incident because it falls under system breakdown and was reported to Quality Assurance and Performance Improvement. It was [Employee #5's name] that delivered the tray containing the shrimp.

Based on observations, medical record review and staff interviews, facility staff failed to provide a resident with food prepared by methods that conserve nutritive value, flavor, appearance, and that is palatable, attractive, and at a safe and appetizing temperature. This was evident for 1 of 3 resident sampled. (Resident #13) The findings included: A review of a facility policy titled Resident Food Services, Resident Meal Service with a revised date of January 2024 documented, part: Provide each resident with a nourishing, palatable, well-balanced, attractive meal, at a safe and appetizing temperature that meets their daily nutritional needs. A review of Resident #13's medical record revealed Resident #13 was admitted to the facility on [DATE] with multiple diagnoses that included: Status Post Reverse Arthroplasty of Left Shoulder, Asthma, Hypertension and Gastroesophageal Reflux Disease. A History and Physical dated 11/03/25 documented in part, Allergies: Shellfish. 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 care plan dated 12/24/25 documented, in part: Nutritional Status: [Resident #13's name] has risk of altered nutrition status . Interventions: Provide diet as prescribed. Note shellfish allergy. Provide nourishment/supplement as ordered. Honor resident's food preferences. A review of the facility's dinner menu dated 12/26/25 documented, in part: Penne [pasta] with Spinach and Shrimp. A Complaint Intake [#2705985] submitted to the State Agency on 12/31/25 at 3:17 PM documented, in part: [Resident #13] has a documented shellfish allergy and the replacement food offered consisted of a peanut butter and jelly sandwich, a ham sandwich, and two bags of potato chips. This is not a nutritionally appropriate dinner for an elderly patient and Subsequent attempts to remedy the situation included three small pieces of chicken served in a plastic container, followed later at approximately 7:03 PM by a container of cold spinach. Due to the continued inadequacy of the response, I was forced to reorder a meal on [Resident #13's] behalf. During a telephone interview conducted on 01/02/26 at approximately 3:32 PM, Employee #3, (Dietary Director) acknowledged the findings and stated that, We have an 'Always Available Menu' (hot and cold menu items separate from the daily menu) that the resident can order from if they can't eat, or don't want what's on the menu for lunch and dinner and there's no cut-off time. It's served on a plate, logged as a special request, and is made to order. I am aware that the alternative food item [served to the resident] was cold, but not aware of how she would've received it in a to-go container.

Based on observation, record review, video footage, staff interviews, and the resident's interview, for two (2) of 50 sampled residents, the facility staff failed to: adequately supervise Resident #165 while the resident sat in the nurse's station on the evening of 06/28/24. Subsequently, the resident eloped through the loading dock door in the facility's basement. On 06/29/24, the police located the resident near a police station (approximately 5.1 miles from the facility). After being evaluated at a hospital, the resident returned to the facility that same day; and (2) ensure Resident #48 was adequately supervised while wearing facility-provided oversize non-skid socks. Subsequently, the resident had a fall with injury (occipital hematoma) on 09/02/24 (Resident #165 and #48). These failures resulted in an immediate jeopardy situation. The immediate jeopardy was identified on September 25, 2024, at 11:50 AM. The facility provided a plan of action to address the immediacy on September 25, 2024 at 5:29 PM and it was accepted. After the plan was verified the IJ was removed on September 25, 2024, at 5:45 PM while the survey team was onsite. After the removal of immediacy, the deficient practice remained due to actual harm, with the scope and severity of G. The findings included: The facility's assessment dated 12/23 documented in part, Management of Health and Behavior- manage the medical conditions and medical-related issues causing .behaviors. Provide care for residents with exit-seeking behavior and/or memory care needs. Provide person-centered/directed care: Psycho/social/spiritual support - identify hazards and risks for residents .prevent abuse/neglect . A review of the Missing Resident (Code Yellow) policy with an approval date of 01/24 documented in part, It is the policy of Ascension's Living to provide a safe and secure environment for all residents. In the event of a resident elopement, policies and procedure will be implemented immediately to locate the resident .The designated code color for a Resident Elopement is YELLOW. When an Elopement Code Yellow is announces, associates will follow the elopement procedure .Charge nurse at the location of the missing person make a determination if the resident is missing (verify resident is not signed out), contact Elopement Commander (Nursing Supervisor) to notify of resident elopement, contact receptionist to announce Elopement Code Yellow. Elopement Commander upon notification form charge nurse will assign search assignments including description and photo of missing resident .if resident is not found in 10 minutes, contact Administrator and Director of Nursing, if resident is not found within 15 minutes contact local police, complete Elopement Drill check list . The Elopement Prevention policy with a review date of 05/24 documented in part, Ascension Living follows processes designed to minimize the risk of harm to the residents living in our community, including risks associated with elopement . Evaluate each resident for degree of elopement risk . on admission [and] approximately 7 days after admission . Resident #165 was admitted to the facility on [DATE] with multiple diagnoses to include Major Depression, Syncope, and Disorientation. A nursing progress note dated 05/07/14 at 3:25 PM documented, Writer received resident at 2:15 PM, in no acute distress. Resident .admitted to [hospital's name] for fall. CT (computer tomography) shows subdural hematoma, and she has a right arm cast. She has a foley cath [catheter] .will continue to monitor. An Elopement Screening and Evaluation dated 05/07/24 documented, Resident is not an elopement risk. An Activity of Daily Living/Functioning/Rehab Potential Care plan dated 05/07/24 documented in part, [Resident #165] needs assistance with daily ADL care. Interventions-mobility need to assistance with 1 person staff support, uses a wheelchair assistive device . A comprehensive admission nursing progress note dated 05/08/24 at 8:16 AM documented in part, Resident .admitted from [hospital's name]. [Resident #165's] diagnosis includes Syncopal Episode, Head Injury, Traumatic Subdural Hemorrhage, Altered Mental Status, and Olecranon Fracture . Resident went to ER after being found down [fall] by neighbors .Resident is alert and oriented to person but confused and impulsive. Resident denied pain, no distress, no discomfort noted .Resident was able to ambulate, AROM (active range of motion) in all four extremities . An admission Minimum Data Set assessment dated [DATE] documented in part that resident had a Brief Interview for Mental Status summary score of 3 indicating that the resident's cognitive status was severly impaired. The resident was also coded for requiring assistance from staff, with acitivities of daily living, and supervision with walking and transferring from chair to bed. Progress notes from 05/09/24 to 06/27/24 lacked documented evidence of staff noting elopement attempts or elopement concerns for Resident #165. An observation of the facility's surveillance camera footage dated 06/28/24 at 6:02 PM showed [Resident #165] walk out the loading dock door on the ground level of the facility without staff supervision. The resident was wearing long blue pants, gray shirt, black long sleeve jacket with hood, and flat black slip-on shoes with white socks. The resident was also noted to have multiple papers in hand including a red folder. At 6:05 PM the resident walked pass the glass front door of the building where the security guard [Employee #20] was stationed. At 6:06 PM the video showed the resident walking toward the parking lot. There was no further footage of the resident after walking into the parking lot. It should be noted at the time of this incident the facility's had one security office on duty on evening shift (3 PM - 11PM). Review of the Elopement Response Record (Checklist) dated 06/28/24 at 9:47 PM documented in part, Resident declared missing at 9:45 PM, Time code (Yellow) was initiated 9:47 PM, Time associates arrived for search assignments 9:49 PM .Resident #165 was located on 06/29/24 . It was noted that the Checklist, however, lacked documented evidence of documentation the resident's description, when and where the resident last was seen, who led the search team, when the administrator, physician, family, police, and DC Health were notified, and where and at what time the resident was located after the elopement. Per World Weather, the following temperatures were listed for 06/28/24. Morning - 59 degrees Day - 86 degrees Evening - 91 degrees Night - 79 degrees https://world-weather.info/forecast/usa/[NAME]/28-june/ A security log dated 06/28/24 documented in part, (Friday) evening shift (3PM-11PM) .9:40 PM Code Yellow (missing resident) called .night shift (11 PM- 7AM) .11:22 PM-both old and new Administrator on site searching for missing resident. 11:33 PM-Nursing supervisor gone out into neighborhood in search of missing resident .and family member on site. 12:35 AM- called 911 (3rd time) waiting for response .1:11 AM-Metropolitan police responded . A security guard incident report dated 06/28/24 documented in part, On my arrival for nightshift .11PM-7AM. I was told that [Resident #165] was missing. Family member and Administrator were all present where all present in search of [Resident #165] for hours till no avail. Police on site .was on site at 1:11 AM .till morning in search of the missing resident. [Surveillance] camera footage showed [Resident #165] making her way through the G (ground0 level back [dock] door . A State Survey Agency Facility Report Incident form (DC~12936) dated 06/29/24 at 3:43 AM documented in part, Writer was informed by one of the nurses on the floor at about 9:44 PM [Resident #165] was not on the floor. According to the assigned nurse [Employee #15, LPN] she saw the resident around dinner time [5:30 PM-6PM] sitting in a chair arranging papers .At 9:47 PM .code yellow (missing resident) was called . all staff searched [residents]rooms .stairwells .outside parameter of the building, and metro station. Security identified [Resident #165] on camera leaving the building via the loading duck [dock] in the basement .At 10:02 PM 911 called . A unit manager nursing note dated 06/29/24 at 4:27 AM documented in part, Writer informed by one nurse on floor at about 9:44 PM that the resident [Resident #165] was not on the floor. At 9:45 PM all units were searched. At 9:47 PM code yellow (missing resident) called. At 9:48 PM Director of Nursing and Assistant Director of Nursing notified. Security identified the resident on camera leaving the building via the loading doc [dock]. Administrator, RP (resident representative), and police notified . A nursing note dated 06/29/24 at 3:55 PM documented in part, Resident was located and ADMIN (Administrator) notified at 2:54 PM, on 06/29/24, [doctor's name] was notified . A nursing note dated 06/29/24 at 11:12 PM documented in part, [Resident #165] returned to the facility from ED at [hospital's name] . accompanied by [responsible party] . resident seen for evaluation .discharge [diagnosis] listed as sever dementia without behavioral disturbance and unspecified dementia .no new medication orders [or] treatment recommendation given .Resident transferred to [secure unit] Resident alert and oriented to person, cooperative, pleasant but confused . Resident was asked where has she been, resident did not respond .head to toe assessment was done .vital signs 97.1, 86, 20, 164/92, oxygen saturation rate 98%. On room air . A hospital Discharge summary dated [DATE] at 7:42 PM documented in part, .presenting for medical evaluation in the setting of leaving her nursing home. Patient has no complaints at this time. Patient exam appears to be at baseline per her mental status and patient vital signs are within normal limits. Given the fact the the patient was outsident for 24 hours in the heat and walking, will make sure patient does not have any kidney issues or other complaints Patient is medically cleared to go back to nursing home . Clinical Impression- Severe Dementia without behavioral disturbance .[and] Unspecified Dementia . A review of the facility's investigative packet dated 06/29/24 revealed written Incident Witness Statement forms statements from all staff who worked the 3-11 PM shift on the unit Resident #165 eloped. Also, noted was Metropolitan Police Department Missing Person Report dated 06/29/24 at 3:33 AM documented in part, Event start date 06/28/26 at 6 PM [and] Event end date 06/29/24 at 3:32 AM . On the listed date and time officers responded to 725 [NAME] Street NE in reference to a missing person. On arrival contact was made with [reporting person] who stated at approximately 1800 [6 PM] hours [Resident #165] walked out the loading dock doors and through the parking lot leaving the facility. [Reporting person] stated that [Resident #165] had Dementia and is not free to leave the facility .due to diagnosis . surveillance video reviewed .Located .missing person [Resident #165] was located at 7th & Indiana Avenue .[Resident #165] was transported by ambulance to [hospital's name] .[Detective's name] advised reporting person and power of attorney that [Resident #165] was located .This case is closed with the location of the missing person . On 08/26/24 an observation revealed that nurse's station was approximately 50 feet away from the elevator on the unit Resident #165 resided on prior to the elopement incident on 06/28/24. It was also noted that no code was needed to access the elevator. Access to the steps, however, required entering a code. From 08/26/24 to 09/05/24, multiple observations showed the resident in the secure Memory Care unit independently walking around the unit. Resident #165 was alert and oriented to name only, but could not provide information about the elopement incident. From 09/05/24 to 09/13/24, two security guards and one receptionist were observed at the desk in the lobby. The observation also revealed that one of the two security guards was sitting in front of a monitor showing multiple views of the facility, including the lower-level hallway and loading dock door. Additionally, a security guard was stationed on the lower level in front of the loading dock doors monitoring everyone entering and exiting. During the face-to-face interview conducted on 09/05/24 at 12 PM, Employee #15 (assigned LPN) reported that the resident was sitting at the nurse's station working on papers at the time of her initial rounds at 4 PM. When she saw the resident again between 5:30 and 6 PM, the resident was still sitting at the nurse's station. After she administered medications, completed documentation, and monitored residents on the west wing around 8 PM - 9 PM, the employee was unable to locate the resident. She then immediately notified the supervisor and other employees on the floor that the resident was missing after the assigned CNA (Employee #21) could not provide the resident's location. A code yellow (missing resident) was announced over the loudspeaker and staff members (on unit and other units) began searching the facility, outside the facility, and around the neighborhood for Resident #165. Police checked the camera and saw that the resident left through the loading dock door. Additionally, she said it was her first time working with the resident, and there was no indication the resident might elope. During a face-to-face interview on 09/05/24 at approximately 3:00 PM, Employee #1 (Administrator) explained that at the time of the incident, she acted as interim administrator and assisted the previous administrator in search of the missing resident. After being found by the police the following day (06/29/24) the resident was taken to the ER for evaluation. Immediately following their elopement, a security guard was stationed at the loading dock doors 24 hours a day. Several elopement drills were conducted. Staff members were also re-educated on elopement risks and drills. When the resident returned to the facility, she was transferred to a secure memory care unit. A security system for elevators is being considered as an additional security measure at the facility. During a face-to-face interview on 09/05/24 at 3:32 PM, Employee #21 (CNA) reported that Resident #165 was sitting at the nurse's station around 5:30 PM when he gave her the dinner tray. After dinner, the resident remained at the nursing station when he picked up the tray. Despite not being able to remember exactly when he picked up the dinner tray, the employee indicated that the resident was at the nurse's station with two licensed nurses at the time. At around 9 PM, the employee looked for the resident to provide care to prepare for bed. At that same time, the assigned nurse asked him where the resident was located. When they couldn't find the resident, they informed other staff on the floor and the supervisor. A code yellow was called, and staff searched the facility, outside, and in the neighborhood, but were not able to locate the resident. He was told that security saw on the video footage that the resident left the facility through the loading dock doors. Additionally, the employee stated that the resident was recently admitted , and never attempted elopement before. During a face-to-face interview on 09/06/24 at 11:06 AM, Employee #20 (Security Officer) stated that the facility had only one security guard on the evening shift before Resident #165 eloped on 06/28/24. She was informed by a nurse that Resident #165 was missing. Her response was to announce a code yellow over the loudspeaker and contact her supervisor. As soon as her supervisor arrived, she received instructions on how to access the facility's cameras. In viewing the footage, they discovered that the resident exited the building around 6 PM on 06/28/24 through the loading dock doors. Before seeing the video footage with her supervisor, she did not see the resident leaving on the monitor. It was explained by her that she could not always look at the monitor because she was busy writing in the log, helping people sign in at the kiosk, providing masks, and locking the loading dock doors at 8 p.m. Around the same time, another resident also went to the hospital on that same evening. In response to the question of whether she saw the resident walk past the glass front door where she was stationed, she replied, No. During a face-to-face interview on 09/06/24 at 1:12 PM, Employee #23 (RN/Unit Manager) stated that the supervisor called her to inform her that Resident #165 was missing. At the time of her arrival, the police and the resident's family were inside the building. She and other employees searched the neighborhood and metro station, but were unable to locate the resident. The police searched the resident's old neighborhood but were unable to locate her. He was reported to have gotten on a bus by a city bus driver. On 6/29/24, police found the resident near the Indiana Avenue police station. After being evaluated at the hospital, the resident returned to the facility and was transferred to a secured unit. The employee also noted that the resident had not previously been at risk of elopement Based on these findings, on September 25, 2024, at 11:50 AM, an Immediate Jeopardy (IJ)-J situation was identified. On September 25, 2024, at 5:29 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: - Resident #165 was identified as missing from the unit on 6/28/24 at 2143pm. - Search of resident was initiated, code yellow called, and elopement process initiated. - Resident was located on 6/29/24 by the DC police and transported to Hospital for evaluation with no findings and treated/released back to the facility on 6/29/24. At 1454 The Executive Director was notified by the Detective that Resident #165 was located on South Indiana; at 2030 Resident #165 returned to [NAME] Manor with no evidence of injury or illness and no new orders and was readmitted to a secure unit with a wanderguard and care plan was also updated on 6/30/24. -On 6/29/24 a complete audit for all residents was completed to ensure all other residents were accounted for and all other residents were identified to be safe within the community. -All residents residing in the community were re-assessed for elopement risk with appropriate interventions and care plans were reviewed and updates made as needed. -All residents had a new Cognition/BIMS assessment completed to confirm current cognitive status. -All resident charts were audited to confirm there is a photo of all residents in the charts. -Other residents residing in the community as of 6/28/24 who do not reside in the secured unit, scored low as an elopement risk, have low cognitive status and the ability to be mobile independently (walking or by w/c) have the potential to be affected. -All doors exiting from a unit were audited to confirm alarms function properly when opened. -Wanderguard system was audited at all secured doors to ensure functioning 1 of 2 -All residents with a wanderguard bracelet had the bracelet checked to confirm functioning, order is in place, care plan is up to date with elopement risk/interventions. - Elopement binder was audited and confirmed it is up to date and available at all times on the receptionist shelf in the lobby on 6/29/2024. - An elopement binder was created and placed at each unit at the nurse's station 6/29/24. -An elopement drill was completed on all three shifts on 6/29/2024. -The dock door that was identified as the resident BH site of exit will be monitored 24/7 by the security company until an alarm can be placed on the door by the alarm company starting 6/29/24. On 9/9/24 a third security guard was added for on-going facility monitoring. -AdHoc QAPI meeting held by the interdisciplinary team on 6/29/2024 to determine root cause of resident's ability to exit community and this plan of correction was developed and implemented. -Medical Director was notified by the charge nurse on 6/28/2024 and is in agreement with this plan of correction. -Staff was re-educated by the Executive Director or designee on 6/29/24 and during their next shift on Elopement Prevention and Missing Resident/Elopement Response, and how to complete the elopement risk assessment to account for cognition/wandering. -The policy and procedure Elopement Prevention has been reviewed by the IDT on 6/29/2024 and has been updated to Policy: Elopement and Wandering Residents. -The IDT has been re-educated by Asst. Director of Nursing to evaluate residents and update care plans upon resident improvements in condition 9/25/24. Completion Date: 9/25/24 2. Resident #48 was admitted to the facility on [DATE], with multiple diagnoses including Repeated Falls, Orthostatic Hypotension, Syncope, Collapse, Generalized Weakness and Difficulty in Walking. An admission Minimum Data Set assessment dated [DATE] documented, the resident was coded section C Cognitive Patterns as having a BIMS score of 14 (Cognitive intact), Section GG Functional Abilities and Goals as requiring Supervision or touching assistance for Self-care: putting on/taking off foot wear (the ability to put on and take off socks and shoes or other foot wear that is appropriate for safe mobility including fasteners, if applicable), for Mobility: roll left to right (The ability to roll from lying on back to left and right side, and return to lying on back on the bed), for Sit to lying (The ability to move from sitting on side of bed to lying flat on bed), for Lying to sitting on side of bed (The ability to move from lying on the back to sitting on the side of the bed and with no back support), for Sit to stand (The ability to come to a standing position from sitting in a chair, wheelchair, or on the side of the bed), for Chair/bed-to-chair transfer (The ability to transfer to and from a bed to a chair (or wheelchair), for Toilet Transfer (the ability to get on and off a toilet or commode), and for Walk 10 feet (Once standing, the ability to walk at least 10 feet in a room, corridor, or similar space). Section J Health Conditions J1700 (Fall history on admission/ Entry or Reentry) Did the resident have a fall any time in the last month prior to admission/entry or reentry was coded as having one (1) fall . A State Survey Agency Facility Reported Injury Intake Form dated at 09/02/24 at 7:41 PM showed Writer was informed by the assigned charge nurse that the resident had a fall. Upon entering into the resident's room with her permission, she was observed kneeling on the floor on her right knee next to the recliner chair in her room. Per the given report she heard and responded to the call for help that was coming from the resident's room and then found her on the floor in the position which I met her. ROM [range of motion] was done to all extremities with no difficulties and resident was then assisted off the kneeling position into her bed for head-to-toe assessment. Resident is alert, oriented and verbally, responsive with no changes noted to her mentation compared to his baseline and very impulsive with constant redirection /reminder to be calm. Pupil equal and reactive to light. Resident did not remember hitting her head on any object. however, there is a raised, soft and slightly tender area in the mid of her head. She was able to move all extremities with no difficulties. Resident c/o pain that is 5/10 to her left hip, area assessed, no swelling, no discoloration, and no external/ internal rotation noted to her lower extremities. She was not able to stand and bear full weight on the left leg neither was she able to ambulate even with her walker. She stated that prior to the fall, she was arranging the flowers on her dresser along with the stacking her food container on her dresser when she lost her balance and fell. She stated further that the fall was probably due to the oversized nonskid socks that she has on. Resident confirmed that she didn't initiate her call light prior to or after falling. Resident room was noted to be cluttered free, the floor was dry and her [NAME] . immediately initiated, ice pack applied to the swollen area on her head and a new pair of medium size nonskid socks was given to the resident. She was also, re-educated/re oriented to the use of call light after encouraging her to always use her call light to call for assistance. On call was notified of the fall along with the resident's initial VS [vital signs] . on room air . new order given to transfer resident via 911 to the nearest ER [emergency room]. Resident and RR [respiratory rate] were updated accordingly. Resident 's Dx [diagnoses]. includes but not limited to Generalized osteoarthritis, HTN [hypertension], DM [diabetes mellitus], Repeated falls, Orthostatic hypotension, Syncope and collapse, generalized weakness and difficulty walking. 911 was called, arrived on the unit and verbal report given along with all the necessary documents (copy of H&P [history and physical], careplan, medication list, recent labs, bed hold policy etc.) 911 left with the resident via stretcher after reassessing the resident to [Hospital name] and her RR was updated accordingly. Review of F/U [follow up] report that was submitted to the state agency on 9/3/2024 7:12AM showed S/p [status /post] Fall: Resident returned from [hospital name] ER to facility at 12:45Am via Stretcher accompanied by 2 ambulance crew, with order to apply ice on the affected area, leave the ice on for 20 minutes, 2-3 times a day for the first couple of days. (slightly raised area in the mid of her head). Assessed resident denies pain and discomfort at this time. VS . Follow up with ER spoke with RN stated CT [computed tomography] scan was done, result revealed Hematoma, no mass, no lesion, Result was not sent with the resident. Resident was made comfortable in bed stable, will continue with plan of care. A nursing progress note dated 09/03/24 at 4:28PM documented in part, F/U [follow up] Resident alert and oriented to name, place and time s/p [status post] fall of 09/02/24 and ER visit. Resident assessed and she verbalized pain to the left hip and the pain has improved as compared to yesterday . assessment done, swollen to the back of the head measuring 4cmx4cm subsided. All over sized nonskid socks were removed and appropriate nonskid socks given currently wearing them Resident did not used call light prior to the fall of 09/02/24 and were reoriented and educated to use the call light at all times. Resident verbalized understanding. The call light placed within her reach. ICE applied the swollen to the back of the head as ordered by MD [physician]. Tylenol 500mg is also administered for pain with good effect. Fall interventions: (1) PT [physical therapy] /OT [occupational therapy] screen/p fall' (2) Offer and assist resident to put on nonskid socks that are medium in size at all times. (3) Reorient /re-educate on the importance of using call light to request for assistance (4) Apply ice to the hematoma at the back of the head three times a day for 5 mins each time. A Root Cause Determination Report dated 09/03/24 document . [resident] had a fall 09/02/24 because she was wearing oversized pair socks, her BIMS score 14, the team met, and the plan of care are as follows: (1) room search was done to remove any oversized socks, but none were found. (2) The resident was encouraged to call for assistance as needed. (3) Staff will offer and assist the resident to put on appropriate size sock /footwear. A care plan with an initiation date of 09/03/24 documented, Problem: [Resident name] had a fall with hematoma to the medial head on 09/02/24. Goal: Offer and assist [resident name] to put on non-skid socks that are medium in size at all times. During a face-to-face interview on 09/06/24 at 10 AM , Resident#48 stated, I should have called for assistance but I did not and the socks I had on did not help. During a face-to-face interview on 09/08/24 at 11 AM, Employee #17 [RN/Unit Manager] acknowledged the finding. The evidence showed that facility staff did not have adequate supervision including monitoring the residents who needed supervision or touching assistance and the use of appropriate footwear to prevent accidents. Subsequently, the resident was observed kneeling on the floor on her right knee next to the recliner chair in her room and the bed wearing oversized nonskid socks. CT scan result showed she sustained a Hematoma measuring 4cmx4cm at the back of the head. There was no witness to Resident #48 falling. Cross Refrerence DCMR Title 22B sect. 3211.1d

Based on record review and staff interviews, facility staff failed to have sufficient nursing staff to provide nursing and related services to assure resident safety based on the Payroll Based Journal (PBJ). The census on the first day of the survey was 175. The findings included: During a Resident Council meeting on 08/27/24, residents complained of low staffing on the weekends causing a delay in getting activities of daily living (ADL) care and services. One resident stated, It's a ghost town in here. Another resident stated, There's hardly any staff here. When I call, they eventually come. They aren't deliberately taking their time, it's just not enough staff to go around. Review of the staffing data submitted via the PBJ system revealed that the facility triggered for excessively low weekend staffing for quarter 2, 01/01/24 to 03/31/24. Review of the staffing for weekends dates of 01/12/24 - 01/15/24, 02/02/24 - 02/04/24, 03/12/24 - 03/15/24, and 03/29/24 - 03/31/24 revealed that the facility failed to provide sufficient nurse staffing creating the risk for the potential for more than minimal harm, that is not immediate jeopardy. During a face-to-face interview on 08/28/24 at 3:00 PM, Employee #2 (Director of Nursing/DON) and Employee #12 (Assistant DON/Staffing Coordinator) acknowledged the findings. Employee #2 stated, Yes, we do have low staffing, especially on the weekends like most other places. We are making efforts to change that. We have a master staffing plan for the weekends and the supervisors make adjustments as needed to accommodate resident care needs. We are doing recruitment fairs, offering bonuses and started hiring more part-time to have more personnel with better flexibility in the building.

Based on observations and interview, facility staff failed to store and distribute foods under sanitary condition as evidenced by food items such as one (1) of one (1) container of mashed potatoes, and one (1) of one (1) open pack of yellow cheese that were not labeled or dated in the walk-in refrigerator, one (1) of one (1) container of pineapple chunks, one (1) of one container of blueberries, and one (1) of one (1) container of canned peaches, that were expired in the walk-in refrigerator, two (2) of two (2) convection ovens that were in need of cleaning, and inadequate breakfast food temperatures from the second floor kitchen. The findings include: 1.Cooked food such as mashed potatoes and ready-to-eat food such as an open pack of yellow cheese stored in one (1) of one (1) walk-in refrigerator were not labeled or dated. 2.Ready-to-eat foods such as a container of pineapple chunks, a container of blueberries, and a container of canned peaches were stored beyond their expiration dated of August 21, and August 24, 2024, in the walk-in refrigerator. 3.Two (2) of two (2) convection ovens were soiled with leftover burnt foods deposits. 4.Breakfast food temperatures from the second-floor kitchen were inconsistent as hot food items such as puree French toast (123 Degrees Fahrenheit °, puree sausage (125.6 °), and mechanical meat (127°), tested below 135°. Employee #19 acknowledged the findings during a face-to-face interview on September 5, 2024, at approximately 11:30 AM. Cross Refrence DCMR Title 22B sect. 3219.1

Based on observations, policy review and staff interviews, for one (1) out of 50 sampled residents, facility staff failed to ensure that licensed nurses had the specific competencies, and skill sets necessary to meet resident needs; and for failed to ensure that licensed nurses met the professional standards of quality for medication administration in three (3) out of seven (7) observations. Resident #64. The findings included: According to the manufacturer's instructions: - BREO (inhaler medication used to treat Asthma/Chronic Obstructive Pulmonary Disease/COPD) can cause serious side effects, including fungal infection in your mouth or throat (thrush). Rinse your mouth with water without swallowing after using BREO to help reduce your chance of getting thrush. - If you are using other inhalers at the same time, wait at least 1 minute between the use of each medication. https://www.mybreo.com/#:~:text=meter%20results%20decrease.-,Your%20healthcare%20provider%20will%20tell%20you%20the%20numbers%20that%20are,your%20chance%20of%20getting%20thrush According to the National Institute of Health (NIH): - It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. - Right patient - means ascertaining that the patient being treated is, in fact, the correct recipient for whom medication was prescribed. This is best practiced by nurses directly asking a patient to provide his or her full name aloud (if appropriate), checking medical wristbands for matching name and ID number as on a chart. - Depending on the unit that a patient may be in, some patients, may not wear wristbands or may have altered mentation to the point where they are unable to identify themselves correctly. In these instances, nurses are advised to confirm a patient's identity through alternative means with appropriate due diligence. https://www.ncbi.nlm.nih.gov/books/NBK560654/ Review of the facility's Administering Medications policy, dated 01/2024, documented: - The individual administering medications verifies the resident identity begore giving the resident his/her medications. Methods of identifying the resident includes checking the photograph attached to medical record/electronic health record; and if necessary, verifying resident identification with other community personnel. 1. Facility staff failed to ensure that Employee #4 (Licensed Practical Nurse/LPN) had the competency, and skill sets necessary to care for residents' needs. Resident #67 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Obstructive Pulmonary Disease (COPD) and Shortness of Breath. Review of the resident's medical record revealed: A physician's order dated 05/14/21 that directed, BREO Ellipta 100/25mcg (micrograms), administer 1 puff by mouth, one time a day for COPD. A physician's order dated 05/31/21 that directed, Spiriva HandiHaler 18mcg, administer 1 capsule with inhalation device by mouth, one time a day for COPD. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 08 indicating moderately impaired cognition. During a medication administration on the 2nd floor on 08/25/24 at 8:35 AM, Employee #4 was observed administering Resident #67 his BREO Ellipta inhaler 1 puff and then immediately after that, administered the Spiriva Inhaler 18mcg via the HandiHaler device. During a face-to-face interview at the time of the observation, Employee #4 was asked why she did not have the resident rinse out his mouth after each administration of the inhalers or wait at least one minute between administrations. Employee #4 stated, I was not aware that I had wait a minute or that I had to make the resident rinse out his mouth after giving the inhalers. 2. Facility staff failed to meet professional standards of quality in three (3) out of seven (7) medication administration observations. A. During a medication administration observation on the 5th floor on 08/26/24 at 9:18 AM, Employee #5 (Licensed Practical Nurse/LPN) failed to verify a resident's identity before attempting to administer the resident her medications. The surveyor stopped nurse before she could administer the medications. During a face-to-face interview at the time of the observation, Employee #5 acknowledged that she failed to verify the resident's identity prior to medication administration and stated, The 5 rights for medication administration are right medication, route, dose, person, and time. I should've checked her name band with the information that is in the computer. B. During a medication administration observation on the 5th floor on 08/26/24 at 9:51 AM, Employee #6 (LPN) failed to verify a resident's identity before attempting to administer the resident her medications. The surveyor stopped nurse before she could administer the medications. During a face-to-face interview at the time of the observation, Employee #6 acknowledged that she failed to verify the resident's identity prior to medication administration and stated that the 5 rights for medication administration were the right patient, medication, dose, time, and frequency. I have been dealing with the resident and know her well, but I could have called someone to come verify her identity with me, but I was already in the room. C. During a medication administration observation on the 4th floor on 08/26/24 at 12:15 PM, Employee #7 (LPN) failed to verify a resident's identity before attempting to administer the resident his medications. The surveyor stopped nurse before she could administer the medications. During a face-to-face interview at the time of the observation, Employee #7 acknowledged that she failed to verify the resident's identity prior to medication administration and made no further comments. During a face-to-face interview on 08/28/24 at approximately 3:00 PM, these findings were brought to the attention of Employee #2 (Director of Nursing/DON). Employee #2 acknowledged the findings and stated that education will be provided.

Based on observations, policy review and staff interviews, facility staff failed to ensure that the established a system for the reconciliation of controlled medications was followed. The findings included: Review of the facility's Controlled Substances policy dated 06/2022 documented: - An individual resident-controlled substance record is made for each resident's medication. - This record contains information to include name of resident, name and strength of the medication, time of administration and signature of nurse administering the medication. - The associate administering medications, who confirmed count at the start of the shift, will maintain the keys to controlled substance. Keys are passed from associate to associate at the time of count. - Associates are to count controlled mediations at the end of each shift. The associate coming on duty and the associate going off duty are to make count together. 1. During a controlled substance reconciliation on the 5th floor, of medication cart 2, with Employee # 8 (LPN) on 08/25/24 at 6:03 AM, it was observed that the [Facility name] Shift to Shift Controlled Medication Count Log showed that on 08/24/24 at 11:00 PM, the on-coming nurse (Employee #8), failed to sign the log to indicate that narcotic reconciliation was completed and that it was correct. During a face-to-face interview at the time of the observation, Employee #8 stated, That's me. I'm the culprit. I forgot. There was an emergency with trying to send out another resident with a low hemoglobin to the emergency room. 2. During a controlled substance reconciliation on the 4th floor, of the north medication cart, with Employee #9 (Registered Nurse/RN) on 08/25/24 at 6:35 AM, the [Facility name] Shift to Shift Controlled Medication Count Log showed the following: A. The assigned nurse, Employee #9, who was in possession of the keys to controlled substances on 08/25/24 at 6:35 AM, was not the staff who signed in the area designated for the oncoming shift on 08/24/24 at 11:00 PM. The nurse whose signature was in the on coming signature for 08/24/24 at 11:00 PM was also noted in the off going signature line for 08/25/24 at 7:00 AM. During a face-to-face interview at the time of the observation, Employee #9 was asked why his signature is not in the book as the person who confirmed count at the start of his shift and was currently maintaining the keys to controlled substances. Employee #9 responded, I don't know. Employee #9 was further stated that he did do the narcotic count but could not explain why there was no documented evidence of his signature in the log book. B. On 08/21/24 at 3:00 PM, the same licensed nurse signed as the off going and in coming staff, indicating that the narcotics were not reconciled by two staff. C. On 08/24/24 at 3:00 PM, the same licensed nurse signed as the off going and in coming staff, indicating that the narcotics were not reconciled by two staff. D. Resident #174's Oxycodone (narcotic pain reliever) Tablet 5mg (milligrams) inventory sheet showed 23 tablets remaining, however the blister packet had 22 tablets remaining. During a face-to-face interview at the time of the observation, Employee #9 stated, I gave her the medication not too long ago. I sign the medication after the resident takes the medication. When asked if that is the standard of practice for narcotic administration, the employee stated Yes. The findings showed evidence that facility staff failed to ensure that the established a system for reconciliation of controlled drugs was followed. During a face-to-face interview on 08/25/24 at 10:45 AM, Employee #2 (Director of Nursing/DON) acknowledged the findings and stated that the findings will be addressed, and that education will be provided. Cross Reference 22B DCMR Sec. 3224.3(d)

Based on observations and interview, facility staff failed to store and distribute foods under sanitary condition as evidenced by food items such as one (1) of one (1) container of mashed potatoes, and one (1) of one (1) open pack of yellow cheese that were not labeled or dated in the walk-in refrigerator, one (1) of one (1) container of pineapple chunks, one (1) of one container of blueberries, and one (1) of one (1) container of canned peaches, that were expired in the walk-in refrigerator, two (2) of two (2) convection ovens that were in need of cleaning, and three (3) of seven (7) hot food items that tested below 140 degrees Fahrenheit (°) during a food temperature assessment on the second floor kitchen on August 25, 2024. The findings include: 1.Cooked food such as mashed potatoes and ready-to-eat food such as an open pack of yellow cheese stored in one (1) of one (1) walk-in refrigerator were not labeled or dated. 2.Ready-to-eat foods such as a container of pineapple chunks, a container of blueberries, and a container of canned peaches were stored beyond their expiration date of August 21, and August 24, 2024, in the walk-in refrigerator. 3.Two (2) of two (2) convection ovens were soiled with leftover burnt foods deposits. 4. Breakfast food temperatures were inadequate and failed to test at or above 140 degrees Fahrenheit (°) on three (3) of seven (7) observations, during a breakfast food temperature assessment on August 25, 2024. Puree French toast (123°), puree sausage (125.6 °), and mechanical meat (127°), tested below 140°. Employee #19 acknowledged the findings during a face-to-face interview on September 5, 2024, at approximately 11:30 AM. Cross Refrence DCMR Title 22B sect. 3258.13

Based on record review, and resident and staff interviews for one (1) of 50 sampled residents, the facility staff failed to notify a resident's physician of the need to start treatment for a resident rash with newly opened lesions. Resident #19. The findings included: Resident #19 was admitted to the facility on [DATE] with diagnoses that included: Congestive Heart Failure, Chronic Atrial Fibrillation, Unilateral Primary Generalized Osteoarthritis, Lymphedema, Presence of Automatic Implantable Cardiac Defibrillator, Diabetes Mellitus, and Difficulty in Walking. An observation on 08/27/24 at 01:33 PM showed Resident #19 lying on his back in bed. The bed linen was pulled up to the resident ' s chest with his upper extremities exposed. A rash with clusters of dry, intact blackhead pimples/lesions was on the resident's outer left upper extremity. During a face-to-face interview on 08/27/24 at 01:33 PM, the resident stated that a rash was also on his outer right thigh. He added that the rashes had been on his arm and thigh for months, but the facility had not treated it. He stated that he had to constantly remind himself not to scratch his skin because the rashes itch. A second observation by the surveyor and Employee # 26 (Licensed Practical Nurse(LPN/Resident #19's assigned nurse), showed the resident lying on his back in bed with the bed linens pulled up to his chest. The resident ' s upper extremities were exposed. The assigned nurse and the surveyor observed a rash on the resident ' s outer left upper extremity, that had clusters of blackhead lesions/pimples. Two of the lesions had bloody pinpoint openings that exposed the skin underneath. A review of Resident #19 ' s medical record revealed the following: A care plan initiated on 05/31/22 documented, (Problem): [First Name of Resident #19] is at risk for pressure ulcers and other skin-related injuries; (Goal): [First Name of Resident #19] will maintain skin integrity without new skin related injuries over the next review period. Goal Date: 10/31/24 .; (Actions/Interventions): Observe for skin redness and breakdown during routine care . A physician ' s order dated 10/06/22 directed, Weekly skin check on Thursdays 7-3 shift (document results in skin & wound module – Every week on Thursdays day shift, for skin monitoring. A review of Resident #19 ' s Weekly Skin Evaluation forms from 06/11/24 to 09/05/24 documented the following: 06/11/24 - General skin check completed – No existing issues . 06/21/24 General skin check completed – No new issues . 06/28/24 - General skin check completed – No new issues . 07/05/24 - General skin check completed – No new issues . 07/12/24 - General skin check completed – No new issue . 07/26/24 - General skin check completed – No new issue . 08/01/24 - General skin check completed – No new issue . 08/08/24 - General skin check completed – No new issue . 08/12/24 - General skin check completed – No new issue . 08/15/24 - General skin check completed – No new issue . Of note, there was no documented evidence that the weekly skin assessments included the rash on the resident ' s upper left extremity or the rash on the resident ' s right thigh. In addition, there was no documented evidence that skin assessments were completed for the resident on 08/22/24 and 08/29/24. During a face-to-face interview on 09/05/24 at 12:01 PM, Employee #27 stated that skin assessments are done weekly and as needed if there is a new concern with the resident ' s skin. The Employee stated that she had been the nurse assigned to Resident #19 over the past month and had been responsible for completing the weekly skin assessments. When asked how she assessed the resident ' s skin, she stated that she looks at the resident ' s skin for any discoloration, new or opened areas on the skin, or, pressure ulcers, and documents in the resident ' s skin assessments. When asked if she was aware of the rashes on Resident # 19 ' s left arm and right thigh, she stated that the resident had them for a long time, and she did not include the rash(es) on the skin assessment because they were not new. During a face-to-face interview on 09/05/24 at 12:07 PM with Employee #28,(5th Floor Unit Manager/, Registered Nurse), she acknowledged that the nurse should have documented the rashes to the resident ' s left arm and right thigh on the weekly skin assessments. She added, that the nurse should have also contacted the physician to see if any further treatment was needed since the resident complained that the rash was itching, and the pimples/lesions of the rash had started to open.

Based on record reviews and staff interviews, for one (1) of 19 sampled residents, the facility's staff failed to provide care consistent with professional standards of practice to promote healing of Resident #2's Moisture Associated Skin Disorder (MASD). Subsequently, Resident #2's sacrum MASD declined to a Stage III pressure ulcer/injury. These failures resulted in actual harm to Resident #2 when it was determined that the resident's Moisture Associated Skin Disorder to the sacrum, first observed on (04/20/2022) was not treated in accordance with the Nurse Practitioners recommendation. Seven days later, the skin disorder further declined, and the resident was observed with a Stage III pressure ulcer/injury to the sacrum. The findings included: Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Cerebral Vascular Accident, Hemiplegia affecting Left Side, Generalized Weakness, and Diabetes Mellitus. Review of District of Columbia Department of Health's Intake Information form dated 07/07/22 documented, [Resident's name] . [had an] infected bedsore . the nurses there neglected to their job, the bedsore was not being treated properly . Review of the resident's medical record showed the following: 12/08/21 {Phuysican order] directed, Cleanse sacrum with soap and water, pat dry, apply A&D ointment TID (three-times-a-day) for protection. 02/15/22 [Significant Change Minimum Data Set] showed the following: Section C (Brief Interview for Mental Status Summary Score) documented the resident had a score of 9 indicating that the resident had moderately impaired cognition. Section E (Behavior) did not code the resident for rejection of care. Section G (Functional Status) coded the resident as requiring extensive assistance from two (2) staff members for bed mobility, being totally dependent on two staff members for toilet use, being totally dependent on staff for bathing, and using a wheelchair as a mobility device. Section GG (Functional Abilities and Goals) coded the resident as always being incontinent of bowel and bladder and not being on a toileting program. And Section M (Skin Conditions) coded the resident for being at risk for developing pressure ulcers and injuries but did not have any at the time of assessment. 04/07/22 [Braden Scale for Predicting Pressure Score Risk] documented the resident had a score of 10 indicating that Resident #2 was at risk for developing pressure ulcers/injuries. 04/07/22 to 04/20/22 [Treatment Administration Record] showed, the nursing staff was providing care per the following order [start date of 12/08/21], Cleanse sacrum with soap and water, pat dry, apply A&D ointment three-times-a-day (6 AM, 2 PM, and 10 PM). 04/20/22 at 12:07 PM [Skin Evaluation] form assessed by Employee #16 (License Practical Nurse/LPN) showed, . sacrum MASD (Moisture Associated Skin Damage) . size - length 2.5 centimeters and width 2.5 centimeters . description - slough not applicable, 100% pink granulating tissue, no drainage, no cellulitis, no foul smell, .Treatment - Z guard cream plus [and] A&D ointment three-times-a-day and as needed . Nurses Notes: Resident was observed with opening on sacrum during ADL (activities of daily living) care by assigned CNA (certified Nurse Aide) .Resident denies pain on assessment. NP (Nurse Practitioner made aware, new order received for Z guard plus [and] A&D ointment tid and prn . (Zguard is indicated to protect minor skin irritation associated with diaper rash and to help seal out wetness. Also protects and helps relieve chapped or cracked skin. https://www.woundsource.com/product/remedy-phytoplex-z-guard-skin-protectant-paste) Review of the physician's orders and the TAR from 04/20/22 to 04/26/22 lacked documented evidence that Z guard cream plus was ordered to treat the resident's MASD. 04/20/22 to 04/26/22 [Treatment Administration Record] showed, the nursing staff was providing care per the following order [start date of 12/08/21], Cleanse sacrum with soap and water, pat dry, apply A&D ointment three-times-a-day (6 AM, 2 PM, and 10 PM). However, there was not documented evidence that nursing staff applied Z-guard. 04/26/22 at 9:00 AM [Physician Progress Note]- eating 25-50 % .no skin breakdown .left sided weakness and contracted . It should be noted, that the physician's note of 04/26/22 at 9:00 AM records that the resident has no skin breakdown, however the resident was noted with MASD to her sacrum on 04/20/22. 04/27/22 at 12:31 PM [Nursing Progress Note] documented - Sacrum Stage 3 measured 4X2 centimeters (length), 4X8 centimeters (width), 40% slough, pink granulating 60%, no cellulitis, mild serous drainage. New order received for [NAME] Na cream plus Santyl ointment two-times-a-day and as needed cover with Allevyn Life (foam dressing), [resident representative name] made aware . 04/27/22 at 20:40 (8:40 PM) [Physician Consult Record] documented, Report- Sacrum Stage 3, 4.2 X 4.8 cm (centimeters), slough 40 %, pink granulation 60 %, mild serious drainage) cellulites. Recommendations - Salna +Santyl bid (two-times-a-day) and prn (as needed), cover with bordered dressing. 04/27/22 at 22:00 (10:00 PM) [Physician Order] directed, Cleanse sacrum wound with normal saline, pat dry, apply [NAME] cream and Santyl ), cover with Allevyn life, twice a day [and] as needed . There was no evidence that facility staff provided the treatment as prescribed by the NP recorded in the Skin Evaluation form dated 04/20/2022. Review of Resident #2's care plan dated 08/30/21 revealed the following: Problem - Pressure Ulcer/Skin Prevention) documented [resident's name] is at risk for pressure injury secondary to her decreased mobility, incont [incontinence] and inability to toilet herself. Goal - [resident's name] will maintain skin integrity without new skin related injures over the next review period. The care plan outlined multiple interventions including observe skin for redness and breakdown during routine care, and [provide] treatment as ordered when needed . During a face-to-face interview on 11/07/22 at approximately 9:00 AM, the resident's physician stated that she was not aware that Resident #2 had MASD wound. However, she was informed by the nursing staff that the resident had a Stage III sacral wound on 04/27/22 at which time she assessed and gave treatment orders. During a face-to-face interview on 11/08/22 at approximately 10:30 AM, Employee #2 (Director of Nursing) stated she did not see where the staff had provided the treatment for Z guard. There was no evidence that facility staff implemented the comprehensive care plan intervention, [provide] treatment as ordered when needed . when they failed to transcribe the physician's order to apply Z guard to Resident #2's sacrum MASD when it was first identified on 04/20/2022. Subsequently, within seven days (04/27/22), Resident #2's sacrum MASD declined to a Stage III pressure ulcer/injury.

Based on observations, that record reviews and interviews, for four (4) of 19 sampled residents, the facility's staff failed to ensure that Resident #1 received adequate supervision to prevent a fall with injury (subdural hematoma) on 11/18/21. Subsequently, following the fall, the resident required surgery repair (left decompressive hemi-craniotomy for evaluation of subdural hematoma). Failed to ensure that: Resident #3 received adequate supervision to prevent an elopement on 03/10/22; Resident #4 was secure in mechanical lift during a transfer which led to the resident having an assisted fall with minor injury (pain) on 06/22/22; and Resident #5 was not secured in bed which led to fall without injury on 09/30/22. (Residents' #1, #3, #4 and #5) These failures resulted in actual harm to Resident #1 The findings included: 1. The facility's staff failed to ensure Resident #1 received adequate supervision to prevent a fall with injury (subdural hematoma) on 11/18/21. Subsequently, following the fall, the resident required surgery repair (left decompressive hemi-craniotomy for evaluation of subdural hematoma). Resident #1 was admitted to the facility on [DATE]. The resident had a history of multiple diagnoses including history of falls, muscle weakness, generalized osteoarthritis, age-related debility, hypertension and epilepsy. Review of Resident #1's medical history prior to admission to the facility revealed a computed tomography scan (CT scan of the resident's head) which showed no cranial abnormalities. A review of the District of Columbia's complaint intake #DC00010417 documented, Did the [resident] suffer any physical injuries? Yes, brain clot surgery [local hospital's name] 11/19/21 . Complaint: 09/18/21- first fall .explanation of injury didn't match what I expected when I saw him [Resident #1] in a video chat. 10/23/21- he [Resident #1] fell again not going to hospital .11/18/21 he fell again doctor wants him to go to the hospital .admitted and had surgery [left decompressive hemi-craniotomy] on 11/19/21 .three falls are two too many should have had a better safety plan for patients [residents]. He came their [there] with a history of fall from 1/2021 .not sure how many other times he fell not witnessed [brain blood] clot is [was] older and during the time he was in the nursing home. Review of the policy tilted, Fall Policy with a last approval date of 01/2022 instructed staff complete the [NAME] II Fall Risk (or similar fall risk evaluation) during admission and quarterly . Review of medical record showed the following: 05/13/21 - The record lacked documented evidence the facility's staff completed a [NAME] II Fall Risk (or similar fall risk evaluation) during the resident's admission. 08/10/21- [Quarterly Minimum Data Set] documented, under Section C (Cognitive Pattern) Resident #1 had a Brief Interview for Mental Status summary score of 9, which suggested that the resident had a moderately impaired cognitive status. Under section E (Behavior)- the resident was not coded for rejection of care. Under section G (Functional Status) the resident was coded for needing extensive physical assistance from one staff person for transfers between surfaces and toilet use, the resident required supervision from one staff member for walking in his room. And used an assistive device (walker) for mobility. Under Section J (Health Condition) the resident was coded for not having any fall since admission. Under Section O, the resident was not coded for receiving physical or occupational therapy services, And Under Section P (Restraints and Alarms) the resident was not coded for using any restraints or alarms. 08/01/21 to 08/31/21- the record lacked documented evidence the facility's staff completed a quarterly [NAME] II Fall Risk (or similar fall risk evaluation). Review of Resident #1's care plans showed the following: Care Plan Problem: [Resident #1's name] requires assistance with related to pain, dementia, and depression with an initial date of 09/02/21. Continue review of the care plan revealed multiple interventions including need extensive assistance with transfers, keep environment clean, clutter free and provide adequate light, keep personal items within reach, complete fall risk quarterly and as indicated. Care Plan Problem -Falls with an initial date of 09/03/21. Interventions included physical and occupational therapy consult as needed 09/18/21 at 4:46 PM [Nursing Progress Note (1st documented fall)] documented, at about 4:30 PM resident was observed on the floor in a supine position in the hallway in front of his room with his walker close by. Resident was observed walking in the hallway towards his room then tripped and fell. Resident stated that he went to get a blanket .tripled [tripped] on his walker and fell. Sustained skin tear to right upper eyelid, swollen measured 3 cm (centimeter) X 0.6 (cm) with minimal bleeding, pressure and ice applied. Resident complained of pain on right eye lid. Dr notified .transfer to ER (emergency room) for further evaluation and treatment . Review of the [NAME] II showed that on 09/18/21 at 5:37 PM the resident had a score of 7 indicating he was a high risk for having falls. 09/19/21 at 10:49 AM [Hospital Discharge Summary] documented, reason for visit- fall and head injury. Diagnoses - multiple closed fractures of facial bone, subdural hematoma, facial hematoma, and facial laceration .you have been seen for a subdural hematoma. On your CT scan it does not look recent and was not caused by today's fall. It was probably from another fall or minor injury at some point in the last few weeks or months . 09/19/21 at 1:55 PM [Nursing Progress Note] documented, resident returned to the facility at 12:00 noon from [local hospital's name] where he was transferred after being observed on the floor .He is alert and verbally responsive .has periods of confusion .steri-strips noted to the lateral area of right brow with no active bleeding, no swelling, no bone protrusion. Discoloration also noted especially around the right eye and right lower eyelid area . 09/19/21 [Hospital After Visit Summary] documented, Reason for visit- fall and head injury. Diagnoses - multiple closed fractures of facial bone, subdural hematoma, facial hematoma, and facial laceration .you have been seen for a subdural hematoma. On your CT scan it does not look recent and was not caused by today's fall. It was probably from another fall or minor injury at some point in the last few weeks or months . 10/23/21 at 10:41 PM [nursing progress note (2nd documented fall)]- at 10:20 PM writer was called by assigned CNA (certified nursing assistant) to report an unwitnessed fall, upon arrival to residents room, resident was found in a sitting position by his chair in his room, when asked what happened stated, I was trying to get up [but] didn't give any other information .head to toe assessment done .no acute distress .initiated neuro-checks .alert but oriented X1 .educated to always call for assistance and verbalized understanding . Care Plan Problem- Falls with an initial date of 10/23/21. Interventions included physical/occupational therapy screen post fall, resident will be queuing to always call for help before any transfer and keep room clutter free, dry floor, and low bed. 11/02/21 [Quarterly Minimum Data Set] documented, under Section C (Cognitive Pattern) Resident #1 had a Brief Interview for Mental Status summary score of 4, which suggested that the resident had a severely impaired cognitive status. Under section E (Behavior)- the resident was coded for rejection of care behavior that occurred 1 to 3 days a week. Under section G (Functional Status) the resident was coded for needing extensive physical assistance from one staff person for transfers between surfaces and toilet use, the resident required supervision from one staff member for walking in his room. And used an assistive device (walker) for mobility. Under Section J (Health Condition) the resident was coded for having one (1) fall with no injury since his admission. Under Section 0 the resident was the resident was coded for receiving occupational therapy services. And, Under Section P (Restraints and Alarms) the resident was not coded for using any restraints or alarms. It should be noted that Section J of the MDS dated [DATE] is inaccurately coded under section J as the resident had two falls within this look back period. 11/17/22 at 11:50 PM [Professional Communication Form (3rd documented fall)] documented, .fall .resident hit his head . temperature 97.1, pulse 56, respirations 20, blood pressure 108/62, pulse ox 98% on room air .resident was more confused, change in behavior, insomnia .transfer to hospital . 11/18/21 at 3:08 AM [Nursing Note] documented, .at 11:50 PM CNA (certified nursing assistant) called to this write's attention and reported resident was observed on the floor .resident was lying on the floor near his bed, [resident's] head was very closed (sp) to the dresser, on assessment noted on the top of his head skin was scrapped, resident was aert [alert] and verbally responsive, [Resident #1] stated [he was] trying to get his socks. 11/18/21 at 5:41 AM [Supervisor Nursing Note] documented, called received for 2nd Floor charge nurse at 11:50 PM that resident was observed lying on the floor close to dresser at the foot of the bed .upon arrival, resident observed in bed resting, with abrasion measured 1 cm (centimeter) X 2 cm not at top of his head .resident stated I was trying to get my socks from the dresser .for work .then I fell , bending down .and hit my head on the dresser .head to toe assessment completed .resident denied pain. Neurological assessment implemented and no changes from resident baseline . Care plan Problem- Fall with an initial date of 11/18/21. Interventions included transfer resident to ED (emergency department) for further evaluation, monitor sleep pattern X 1 week, anti-roll back wheelchair for safety when out of bed, and corner guard applied to edges of furniture in resident's room. 11/20/21 at 1:39 PM [Nursing Progress Note] documented, . the ER (emergency room) nurse informed writer that resident was admitted [to] .medical surgical ICU (intensive care unit) on 11/18/21, and ICU nurse informed writer that there was no discharge plan for resident yet. 12/02/21 at 7:59 PM [Nursing Progress Note] documented, resident .re-admitted to facility at about 2:30 PM from [local hospital's name] after being treated for subdural hematoma evacuation after a fall .he is alert, awake, oriented to self .resident was re-admitted to the unit with diagnoses of subdural hemorrhage .left side of head surgical site sutures intact, dry and healing progresses well . 12/02/21 [Hospital Discharge Summary]-CT head shows bilateral subdural hematomas. Pt taken to the operating room for left decompressive hemi-craniotomy for evacuation of subdural hematoma. 11/19/21- admitted to surgical intensive care unit status-post fall with bilateral SDH (subdural hematoma) L > R with left to right shift. Radiology review details shows .Bilateral subdural hematoma (subacute/chronic with questionable acute superimposed subarachnoid hemorrhage versus artifact .There is a mild rightward midline shift .Discharge Diagnosis - Subdural Hemorrhage present on admission. A review of rehabilitation notes showed an occupational therapist progress and discharge summary note dated 11/23/2021, documented, the resident started care from 09/21/21 to 11/18/22 .Indoor mobility (ambulation) -resident needed partial assistance of another person to complete activities .functional transfer from sit to stand [the resident required] stand by assist (close enough to reach patient if assistance needed) .precautious -falls .patient was unexpectantly discharged to hospital. The complainant stated during a telephone interview on 10/25/22 at approximately 2:30 PM, The staff took insufficient care of my dad (Resident #1). The complaint stated that the resident fell for the first time on 09/18/21. According to the complainant, the staff kept giving her conflicting explanations about the (09/18/21) fall because her dad didn't look like what the nurses described. She said that Resident #1 looked horrible, with a black and blue face, a fractured nose, and an eye fracture. Also, the staff called her an informed that Resident #1 suffered a second fall on 10/23/21, but he did not require a hospital transfer. The complainant also said, Her father had to have an operation to remove a brain blood clot after his third fall on 11/18/22. During a face-to-face interview on 10/28/22 starting at 2:31 PM, Employee #3 (Rehab Director) stated that staff should have provided stand by assist (been no more than an arm length away from resident for safety). When asked, if staff should have been at least an arm length away from Resident #1 with the fall on 10/23/22, Employee #3 stated, yes. Additionally, the employee said that according to the therapy notes Resident #1 was not safe to ambulate independently in his room on 11/18/21. He required the assistance from another person to complete the activity. When asked, how is nursing staff made aware of the recommendation for rehab, Employee #3 stated they are discussed weekly during utilization review meetings. The employee was asked for copies of the utilization review notes at the time of the interview; however, the notes were not provided to the surveyor for review. During a face-to-face interview on 10/29/22 at 5:00 PM, Employee #4 (Occupational Therapist) was asked how was nursing staff made aware that the resident required stand-by-assistance with transfers and assistance from staff with ambulation? The employee said that he made nursing staff aware of the assistance the resident required during a care plan meeting on 09/23/21. Employee #4 also stated that Resident #1 was impulsive. During a telephone interview on 10/31/22 starting at 12:14 PM, the resident's physician stated that Resident #1's daughter brought the resident to the nursing home because he was falling at home. According to the physician, the resident failed to call for help, which led to him falling. The physician stated, How can we control him if doesn't call for help. When we have patients with dementia, they may refuse care (call for assistance from staff). I asked nursing staff for one-to-one care for him [Resident #1], but they told me that they don't have one-to-one services. Additionally, the physician, stated that he could not remember what nurse he talked to about one-to-one services for the resident. During a face-to-face interview on 10/31/22 starting a 12:20 PM, Employee #2 (DON) who was present doing the telephone interview with the previously mentioned telephone interview with the resident physician, said that the physician was right when he said the facility does not offer one-to-one services for residents. The employee was then asked how did you keep Resident #1 safe from falls? The employee said we moved him closer to the nursing station. The employee was then asked how was that an arm length away as recommended by rehab. The employee failed to provide an answer. 2. The facility staff failed ensure Resident #3 received adequate supervision Subsequently, the resident eloped from the facility on 03/10/22. Resident #3 was admitted to the facility on [DATE] with multiple diagnoses including Alzheimer's Disease and Dementia. Review of a District of Columbia Intake form #DC00010619 documented, .the resident was missing from the unit at 5:15 PM .Another staff from the activity department brought the resident to the unit at 5:30 PM .the resident [was] on 12th [NAME] Street NE (at the entrance of the campus of the facility). Resident was assessed .no skin bruises, discomfort, distress .She thought she could walk outside to get some fresh air on her own . During an observation on 11/03/22 at approximately 10:00AM, Resident #3 was walking around the talking and laughing with other residents. The resident had on a wander/elopement alarm (bracelet) on her ankle. She was oriented to her name only and unable to recall the incident when she wandered away from the facility on 03/09/2022. Further observation showed the unit was secured (locked) with monitors and alarms to capture people entering and exiting the unit. Review of the resident's medical record showed the following: 07/15/21 [Physician Order]- Roam alert for safety monitoring- check placement every shift . 01/31/22 [Quarterly Minimum Data Set] showed Under Section C (Cognitive Pattern) the resident a Brief Interview of Mental Status summary of 3 indicating the resident was severely impaired cognitively. Under Section E (Behavior)- the resident was not coded for refusal behavior. Under Section G (Functional Status)- the resident was coded for activity did not occur for locomotion off the unit, needing supervision of one staff member when walking in the corridor, and needing set-up for walking in her room. Under Section O- the resident was not coded for receiving psychological therapy. Under Section P (Alarms) the resident was coded for using a wander/elopement alarm daily. 03/01/22 to 03/09/22 [Medication Administration Record] showed that nursing staff was checking the placement of the wander/elopement alarm every shift. 03/09/22 at 10:26 PM [Nursing Progress Note] documented, At 4:30 PM this writer noted resident was in her room alert and verbally responsive with her room alert on her right wrist but non-compliant in keeping it on. At 5PM this writer notice resident was not in her room .We searched for the resident .within the unit. While searching .activity personnel show up with resident. She reported that the resident on 12th and [NAME] Street .On assessment [resident] is calm, no distress noted .and without her room alert (wander/elopement device). A new room alert was immediately place on resident and its working properly . 03/09/22 [5 Working Day/Final Report] documented, .Summary of Investigation; Ms. [NAME] left the memory care unit, when a visitor held the door open for her. The following actions are in place to prevent further exits: Notice was sent to RR (resident representative), unit access and exit changed, and staff was re-educated on the elopement prevention process. 03/10/22 at 7:45 AM [Physician Progress Note] documented, Resident was found by staff member outside the building on the street, left outside the unit with some other family member no injuries noted .PT (patient) to keep roam alert (wander/elopement alarm). 03/15/22 at 4:01 PM [Social Work Progress Note] documented, A care plan meeting was held 3/14/22 to address [resident's name] elopement on 03/09/22. In attendance virtually .[two family members names]. How [resident's name] managed to get off the unit was explained: she was unintentionally let out of the unit at 5:13 PM by another resident's family member, she was returned to the unit by staff at 5:27 PM. Family .watched the security footage (video) of the elopement .In order to prevent any future risk of elopement, the security code for the floor has ben changed and will not be disturbed to family or visitors. All visitors to the unit will need to be escorted onto and off the unit by staff .[resident's name] is also wearing a roam alert bracelet. Review of the resident's care plan showed the following: 08/14/21 - Problem- [Resident's name] is at risk for .elopement. Intervention included follow community elopement evaluation and monitoring process . 10/01/21 - Problem - Potential for elopement from the facility secondary to dx (diagnosis of dementia/verbalized intentions to leave the facility. Interventions included apply roam mate bracelet as ordered, access .for potential to wander, replace roam alert if becomes lost, orient to surroundings . 01/07/22 -Problem [Resident's name] has impaired behavior related to exit seeking, hovering around the exit doors (with a start dated on .Interventions included nursing to re-direct resident when standing at the exit door . During a face-to-face interview on 11/03/22 at approximately 3:00 PM, Employee #5 (Activity Assistant) stated that when she was going home for the day, she saw Resident #3 at the back of the hospital (located on the same grounds as the nursing home). She escorted the resident back to the nursing home. During a face-to-face interview on 11/03/22 at approximately 4:30 PM, Employee #1 (Administrator) stated that they looked at the security video and saw that that another resident's family member let Resident #3 out of the unit. When asked, if the alarm went off when resident went through the door, the employee stated no because she did not have her wander/elopement alarm on at the time. She removed the alarm. We put a care plan in place for removing her wander/elopement alarm. 3.The facility's staff failed to ensure Resident #4 was secure in a mechanical lift during transfer which led to the resident having an assisted fall with minor injury (pain). Review of District of Columbia Intake form #DC00010829 dated 06/22/22 documented, .resident was transferred with a full body mechanical left [lift] to the bed to wheelchair with 2 staff .in an attempt to adjust the mechanical pad left underneath her for comfort while in the wheelchair, suddenly resident slide off the wheelchair to the floor in a sitting position in front of her wheelchair .she reported pain to left hip on touch and by nodding her head, no swelling noted, and skin warm and dry to touch. During an observation on 11/10/22 at 8:45 AM showed Resident #4 alert, non-verbal, totally dependent on staff for activities of daily living. When asked about the fall on 06/22/22, the resident hunched her shoulders indicating that she did not know about the fall. Review of the resident's medical record showed the following: Review of Resident #4's care plans showed the following: 08/19/21 - Problem- [Resident's name] needs assistance with daily activities of daily living care. Interventions included .need total assistance with mobility .need one person staff support mobility .use wheelchair device for mobility 08/19/21 - Problem- [Resident's name] has a potential for falls related to hx (history) of seizure activity. Interventions included assist with all transfers and mobility prn (as needed) 05/31/22 [Annual Minimum Data Set] showed the following: Under Section C (Cognitive) Brief Interview for Mental Status summary score of 12 indicating the resident intact cognitively. Under Section G (Functional Status) the resident was coded for extensive assistance from one staff member for transferring between surfaces and uses a wheelchair for mobility. Under Section J (Health Condition) the resident was not coded for fall since her admission to the facility. Under Section O (Special Treatments, Procedures and Programs) the resident was not coded for receiving occupational/physical therapy services. 06/22/22 at 1:09 PM [Nursing Progress Note] documented, Nurse was called to the hallway by resident's assigned CNA (certified nursing assistant) at 11:30 AM .resident was observed sitting on the floor in front of her wheelchair with legs stretched out .about .1:00 PM .resident identified that she is feeling pain now on her left hip. Tylenol 500 mg (milligrams) po (by mouth) was given for pain. Order received for x-ray of left hip . 06/22/22 [Physician Order]- X-ray of left hip for pain post fall. 06/23/22 [Physician Progress Note] documented, Transferred from bed to chair with [name of mechanical lift] but slid and fell to floor . left hip WNL (within normal limits) . Some pain with adduction . Xray of (left) hip negative. Lower back pain on exam. Assessment/plan- status post fall, LT (left) lower back pain, ice TID (three-times-a-day), Naprosyn 500 mg (milligrams) BID (two-times-a-day) for 10 days. X-ray of lower back. 06/23/22- [X-Ray Results of Lumbar Spine] documented, Vertebral bodies are normal .Impressions; mild-to-moderate degenerative changes in lumbar spine . Review of the facility's investigative notes showed the following: 06/22/22 [Incident Witness Statement Form] from assigned certified nursing assistant, documented, We were transferring the incident [resident] in her wheelchair. While we were adjusting the pad to make her comfortable. She started sliding, so we lowered her to the floor in front of her wheelchair . During a face-to-face interview on 11/10/22 at approximately 1:00 PM, Employee #7 (Activity Assistant) stated, Staff was trying to put the resident in her wheelchair. Because the blue sling (used with mechanical lift) was not under the resident properly, she (Resident #4) started to slide forward. When she started sliding forward, I helped the two staff members assist her down to the floor in front of her wheelchair. 4. The facility's staff failed to ensure Resident #5 was safe in bed which led to a fall without injury on 09/30/22. Resident #5 was admitted to the facility on [DATE] with multiple diagnoses including hemiplegia, muscle weakness, and need for assistance with personal care. Review of the District of Columbia's Intake Information form #DC00011009 documented, [At 8:00 AM .Resident #5's name was observed lying on the floor beside her bed on her right side with both of her legs stretched out .alert, oriented to name and place .reported she rolled out of the bed to the floor and refused hitting her head .At 9:30 AM resident noted lethargic and difficult to arouse .transferred to [local hospital's name] . An observation was conducted at 10:30 AM on 11/10/22 revealed Resident #5 was lying in bed, on her back and the bed was in high position (from the floor). The head of bed elevated at a 45-degree angle, and quarter side rails in up position. The resident was not eating at the time of the observation. Employee #13 (LPN/Licensed Practical Nurse) was called to the bedside. The employee lowered the bed and stated, She is a fall risk and it's not safe to leave her bed elevated that high. The staff may have left the bed elevated when she was eating. Review of the resident's medical record showed the following: Review of the resident's care plan dated 11/27/21 showed the following: Problem [Resident's name] fell . Further review of the care plan revealed multiple interventions including place bed in lowest position while in bed . 09/20/22 [Quarterly Minimum Data Set] documented, Under Section C (Cognitive) the resident had a Brief Summary Score of 11 indicating the resident was intact cognitively. Under Section E (Behavior) the resident was not coded for rejection of care. Under Section G (Functional Status) the resident was coded for requiring extensive assistance from two or more staff members for bed mobility. Under Section J (Health Condition) the resident was coded for have one fall since admission. Under Section O (Special Treatment, Procedures, and Programs) the resident was coded for receiving occupational therapy services, and Under Section P (Restraints and Alarms) the resident was not coded for using physical restraints or alarms. 09/27/2022 [[NAME] II Fall Risk] documented that the resident has a score of 11 indicating that the resident was a high Risk for falls. 09/30/22 at 11:08 AM [Nursing Progress Note] documented, At 8:00 AM .[Resident #5] was observed lying on the floor beside her bed on her right side with both of her legs stretched out .alert, oriented to name and place reported she rolled out of the bed to the floor and refused hitting her head. Denies pain or discomfort. Resident bed in low position . assisted from the floor by 3 staff to bed via full body mechanical lift . denies dizziness . no apparent injury noted . v/s (vital signs) 117/74 (blood pressure), 78 (pulse), 20 (respirations), 97.5 (temperature) . At 9:30 AM resident noted lethargic and difficult to arouse .transferred to [local hospital's name]. 09/30/22 at 8:08 PM [Nursing Progress Note] documented, writer placed call to [local hospital's name] .nurse stated [Resident #5] was admitted . 09/30/22 [hospital discharge summary] documented, Active problems principal urinary tract infection . ED (emergency department) course: . UA (urinary analysis) consistent with UTI (urinary tract infection), CT of the head no acute intracranial hemorrhage .Hospital course- UTI confirmed . in urine culture . patient will complete course of (oral) antibiotics X 2 days . Other medical issues are stable at this time . During a face-to-face interview on 11/10/22 at 12:10 PM, Employee #13 (LPN), who was the resident's assigned nurse on the day of the fall stated, The resident was trying to reposition herself in the bed, and she rolled onto the floor on the left side of her bed. The bed was in low position. When ask was the resident's side rail up? The employee said, The side rail was not attached to the bed. It was up against the wall. I don't if it was broken. Cross reference DCMR 3211.1

Based on record review and staff interview, for one (1) of 60 sampled residents, facility staff failed to provide supervision, monitoring and modification of the residents plan of care to decrease the resident ' s risk for falls. Resident #51, who had a history of falls with injury, sustained another subsequent fall with injury. The findings included: Resident #51 was admitted to the facility on [DATE]. The medical record revealed the resident had multiple diagnoses including Dementia, Generalized Muscle Weakness, Wandering, History of Falling, Left Artificial Hip Joint, Fracture of Neck of Left Femur and Age-Related Physical Debility. Review of the medical record revealed the following: 04/15/2021 at 2:37 AM [Nursing Supervisor Note] .I saw the resident sitting on the floor in front of her room .Resident complained of severe pain in her left hip .The resident is alert to herself but confused .We did not move or turn the resident from the floor .MD (medical doctor) said to send resident ot [to] hospital for evaluation and treatment .911 crew arrived . [Resident #51] left facility at 1:14AM . Resident #51 was readmitted to the facility on [DATE] with a diagnoses of Left Hemiarthroplasty (a surgical procedure that involves replacing half of the hip joint). 04/23/2021 [Physician ' s Progress Note] MD (medical doctor) readmission .patient was sent to [hospital name] s/p (status post) fall sustained left hip fracture s/p (status post) left hemiarthroplasty . .Review of Resident #51 ' s Fall Risk Assessments revealed the following: On 04/15/2021 - the resident had a score of 14. On 04/22/2021 - the resident had a score of 24. On 06/04/2021 - the resident had a score of 20. According to the fall risk assessment, A resident whose score is over 9 is at risk for falls. Review of the Significant Change Minimum Data Set (MDS) dated [DATE], revealed the following: In section C (Brief Interview for Mental Status - Summary Score) - the resident was coded as a 3 indicating that the resident was severely impacted cognitively. In Section E (Rejection of Care) -the resident was coded as behavior not exhibited. In Section G (Toileting Use) - the resident was coded as total dependence and requiring one-person physical assist. In section G (Mobility Device) - the resident was coded as using a wheelchair. In Section J (Health Condition - Fall History/ Recent Surgery)- the resident was coded as having fracture related to fall and having major surgery. In Section M (Other Ulcers, Wounds and Skin Problems) - the resident was coded as having a surgical wound. In Section O (Special Treatments, Procedures, and Programs) - the resident was coded as receiving speech, physical and occupational therapy services. In Section V (Care Area Assessment Summary) - indicated that the resident triggered for falls, which were addressed in the resident ' s care plan. Review of the Fall Care Plan with a start date of 10/23/2018 outlined multiple intervention including: Initial interventions: Complete Fall Risk Assessment quarterly. Encourage resident to request assistance, as needed. Encourage resident to rise slowly and sit in upright position before attempting to transfer. Keep frequently used items in easy reach. Revised interventions after fall on 04/15/2021: PT/OT (physical therapy/occupational therapy) Screen. Transferred to ER (emergency room ) Left hip hemiarthroplasty It should be noted that the 10/23/2018 interventions were still being implemented. There was no evidence that facility staff revised the plan of care and or facility practice with goals and approaches to reduce the likelihood of another fall for Resident #51 who has a history of a fall with injury and is cognitively impaired. Review of therapy documents revealed the following: Physical Therapy Plan of Care with a start care date of 04/23/2021 and end date of 06/02/2021 revealed, . Treatment diagnosis - aftercare following joint replacement surgery . Frequency/duration of services were four (4) times a week for 60 days Resident #51 required skilled services to focused on . therapeutic exercise, neuromuscular re-education, gait training, manual therapy, physical therapy evaluation moderate complexity, and therapeutic activity. The Physical Therapy Progress & Discharge Summary dated 06/02/2021 documented, Patient has achieved 100% of rehab goal at this time and to be d/c (discharged ) to LTC (long term care) with assistance from nursing staff as needed .Pt (patient) educated in order to improve functional mobility .Pt (patient) educated on safety precautions in order to decrease .falls .Pt. requires *CGA (contact guard assist- the assisting person has one or two hands on your body but provides no other assistance to perform the functional mobility task) -*SBA (stand by assist- the assisting person does not touch you or provide any assistance, but needs to be close by for safety in case you lose your balance or need help to maintain safety during the task being performed.) for safety mobility . The therapy discharge summary indicates that Resident #51 (who was assessed as cognitively impaired) was educated. However, there was no evidence in the discharge summary that the resident verbalized understanding or was able to return demonstration of the material she was taught. On 07/27/2021 at 7:50 AM [Physician Geriatric Progress Note] - Pt (patient) c/o (complained of) severe pain rt (right) hip . she said [that she] fell down while trying to go to bathroom and got back to bed herself . transfer to ER (emergency room ) acute severe pain . 07/27/2021 at 8:00 AM [Telephone - physician order] - Transfer resident via 911 to ER (emergency room ) for acute severe right hip pain. 07/27/2021 at 9:45 AM [Nursing Note] - Writer ' s attention was called to the resident ' s room secondary to complaining of pain in her right hip during care . that won ' t go away . Resident . remained alert, oriented to her name only and able to verbally make her needs which is her baseline secondary to diagnosis of Dementia .Resident confirmed that she did not tell anyone that she fell . prior to now . 911 called .first responder in house . left with resident via stretcher to [hospital name] . During a face-to-face interview conducted on 07/28/2021, at approximately 10:30 AM, Employee #26 (Director of Rehabilitation) stated that the resident required moderate assistance with transfers. She then said she did not see any evidence that therapy staff provided nursing staff education on safety issues including contact guard assist and stand-by assist to reduce falls and improve functional mobility for Resident #51. During a face-to-face interview conducted on 07/28/2021, at approximately 11:00 AM, Employee #5 (4th floor Unit Manager) acknowledged the findings.

Based on resident and staff interviews and record review, facility staff failed to ensure that Resident #1 was free of unnecessary antipsychotic drugs. On (MONTH) 18, 2019, at 6:10 PM an Immediate Jeopardy (IJ)-K was identified at CFR§ 483.45 (d) (4), F758. On (MONTH) 18, 2019 at 7:05 PM, the facility's Administrator provided a letter to the State Agency Survey team documenting the corrective action plan, as follows: 1. A review of all residents in the facility to ensure that there is an appropriate [DIAGNOSES REDACTED]. 2. Education to all staff to ensure that residents have appropriate [DIAGNOSES REDACTED]. 3. The nurse managers and supervisors will continue to randomly audit 20% of physician orders [REDACTED]. Record Review Resident #1was admitted to the facility on (MONTH) 26, (YEAR). According to the Minimum Data Set (MDS) with a target date of (MONTH) 11, 2019, Resident #1 scored 9/15 on the Brief Interview for Mental Status in Section C (Cognitive Patterns). According to the MDS 3.0 User's Manual page C-14, a score of 8-12 suggests that the resident has moderately impaired cognitive skills for daily decision making. Resident #1 was assessed as requiring extensive assistance for all Activities for Daily Living and totally dependent for bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to Section N (Medications) -N0-400 Medications received - antipsychotic - (blank) According to a nurse's note dated (MONTH) 26, 2019 at 16:50 (4:50 PM): Dr's appointment , resident [DIAGNOSES REDACTED]. Family representative her daughter was in unit and notified, follow up appointment in 3 months due October. New order for [MEDICATION NAME] 0.5 mg 1 tablet po at bedtime and [MEDICATION NAME] 0.25 mg 1 po daily no unusual behavior noted call light within reach. According to www.nih.gov: [MEDICATION NAME] is an atypical antipsychotic that is used widely in the treatment of [REDACTED]. Resident #1 returned from the psychiatrist's appointment with two (2) pages for the consult, stapled together. Page 1 had Resident #1's name on the top of the page. However, page 2 had Resident #2's name on the top of the page. Treatments for Resident #2 included Consider decreasing [MEDICATION NAME] to 0.5 mg po q hs and 0.25 mg po q am/GDR/ Patient is stable clinically at this point. Continue with supportive interventions/ return to clinic in 3 months Employee #1 (Evening Charge Nurse) did not notice that page two (2) of the consult was a different resident from page one (1) when he/she transcribed the order. The order was transcribed and Resident #1 received Resident #2's medication of [MEDICATION NAME] from (MONTH) 27, 2019 through (MONTH) 26, 2019 (31 days). Review of the Medication Administration Record [REDACTED]. The additional 14 doses were administered by eight (8) additional nurses, that consisted of PRN and float nurses. The primary care physician signed the telephone order on (MONTH) 27, 2019. A telephone interview was conducted with the (psychiatrist) on (MONTH) 18, 2019 at 3:30 PM. The psychiatrist stated, My office staff mixed up the reports. That doesn't happen very often. The psychiatrist was asked if [MEDICATION NAME] was a medication he would prescribe for Resident #1. The psychiatrist stated, No, (Resident #1) does not exhibit any behaviors that I would use this drug for her. A face-to-face interview was conducted with Employee #1 on (MONTH) 18, 2019 at 3:15 PM. Employee #1who stated, I transcribed the order and called the (primary care doctor) who approved the order. Employee #1 was asked if he/she knew what the drug was for and stated, behavioral issued. Employee #1 was asked if Resident #1 had any behavioral issue and stated, No, not that I know of. Employee #1 acknowledged that he/she was administrating a drug that he/she did not know what the drug was given for or any side effects that needed to be monitored. Employee #1 was asked what the drug was prescribed for and stated [MEDICAL CONDITION]. Employee #1 was asked what behaviors he/she would monitor and stated we have a pamphlet in the med cart. After retrieving the pamphlets (laminated sheets with drugs and side effects listed) read the off label use that included stuttering, [MEDICAL CONDITION], Tardive dyskinesia, [MEDICAL CONDITION] in Parkinson disease, management of agitation and psychotic events in patients with dementia and [MEDICAL CONDITION], Obsessive-compulsive disorder - adjunct therapy, post-traumatic stress disorder and [MEDICAL CONDITION] in the critically-ill patient. Employee #1 acknowledged that he/she had never seen Resident #1 exhibit any of the above listed behaviors. He/she stated that the primary care physician signed the order. A face-to-face interview was conducted with Employee #2 (Day Charge Nurse) on (MONTH) 18, 2019 at 2:30 PM. He/she was asked if he/she knew what [MEDICATION NAME] was given for and responded, antidepressant. Employee #2 was asked if he/she had checked what the drug was, stated no and was asked how he/she could find out about the drug. Employee #2 sat down in front of the computer in the charting room and within two (2) minutes, had identified the drug, its uses and side effects. Employee #2 acknowledged that Resident #1 had never exhibited aggressive behaviors. He/she stated that the primary care physician signed the order for the [MEDICATION NAME]. A face-to-face interview was conducted with Employee #3 (Medication Nurse) on (MONTH) 18, 2019 at 3:00 PM. He/she was asked if he/she knew what [MEDICATION NAME] was given for and responded, for calming a resident. Employee #3 was asked if he/she knew if Resident #1 ever exhibited these types of behaviors and stated, I haven't seen (Resident #1) agitated or aggressive. (Resident #1) will tell you what he/she wants but I have never seen (Resident #1) agitated. I didn't think the drug was unusual because other residents in the facility take it. I am a floater and I am on that floor every now and then. In-services were initiated on (MONTH) 28, 2019 as a result of this incident. The in-service included reading the whole consults, checking to ensure the same resident is included in a multiple page consult. A copy of the consults will now be given to the unit manager for review. The nurse manager will review the consult for correct transcription of medications and ensuring that the right resident receives the prescribed medication. The Pharmacist's Chronological Record of Medication Regimen Review was completed on (MONTH) 5, 2019. There were no irregularities identified. The pharmacist failed to recognize that [MEDICATION NAME] was a new medication, and failed to investigate if [MEDICATION NAME] was an appropriate drug for Resident #1. This was acknowledged by Employees #4 and 6 on (MONTH) 18, 2019 at 6:10 PM. The record was reviewed (MONTH) 18, 2019.

Based on staff interview and record review for Resident #1, it was determined that facility staff failed to properly position Resident #1 in bed. The resident subsequently fell out of bed and sustained facial injuries. The findings include: Resident #1 was admitted to the facility on [DATE]. According to a Minimum Data Set (MDS) assessment with an assessment reference date of July 25, 2015, Resident #1 achieved 00/15 on the Brief Interview for Mental Status. According to the MDS 3.0 User ' s Manual page C-14, a score of 0-7 suggests that the resident is severely cognitively impaired. Resident #1 was assessed as being totally dependent for all Activities of Daily Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated August 15, 2015 at 17:28 (5:28 PM): Upon arrival to the unit, CNA notified writer about resident. When I entered the room, resident was observed in the bed with RN supervisor and other staff were attending to the resident who sustained laceration to the left forehead and swelling to the left check. Laceration with minimal bleeding, pressure applied to the area. Not in any distress. Respirations even and unlabored. Pupil equal and reactive to light. Tylenol administered by team leader as ordered. (Doctor) was notified at 15:25, new order to transfer resident to ER for evaluation secondary to fall. 911 was called at 15:28. 911 crew arrived at the unit at 15:50. Resident left the unit at 16:00. No changes in the level of consciousness. (RP) notified. VS T 98.2, R 20, p 82, BP 177/72, 02 Sat 98% on room air. According to a nurse ' s note dated August 17, 2015 at 21:43 (9:43 PM): Resident was readmitted from (Hospital) via ambulance stretcher at 2030 (8:30 PM) with [DIAGNOSES REDACTED]. Resident is alert and awake not verbally responsive during assessment. Resident left forehead laceration is intact and dry with no signs of infection noted, her left eye corner is reddened with minimal swelling around the left eye. Resident pupils are equal to light and accommodations. Her range of motion is within her normal limit. CT scan of the spine shows 1) slightly increased atlantodental interval. Ligamental injury not excluded, small ossific fragment just above the anterior C1arch without an identifiable donor site, likely chronic. No definite acute fracture identified. 2) Severe multilevel degenerative disc disease. Straightening of the normal cervical lordosis may represent underlying muscle strain. CT scan of the head shows no evidence of acute hemorrhage and CT of the face shows extensive left facial edema and infraorbital hematoma. No acute facial fracture. (Doctor) on call made aware, no new orders but confirmed re-admission medication orders. B/P 154/86, P 77, T 98.3, R 20, Weight 109.7 lbs. According to a physician ' s note dated August 19, 2015 at 1608 (4:08 PM): [AGE] year old female reported to have had a fall 3 days ago. Seen in ER for head trauma. Head CT showed only facial hematoma but no fracture. Today alert, answers a few questions, no distress, no reported change in behavior. BP 132/76, pulse 72, No acute distress, alert, small 1 ½ mm laceration left supraorbital area. With small hematoma non-tender - no drainage - pupils equal, seems clear, area clean. Neck - non-tender Lungs - clear Heart - regular Neuro - equal motor strength CNS - grossly intact S/P - head trauma, (unable to read) laceration forehead Disposition: clean laceration A face-to-face interview was conducted with Resident #1 on August 24, 2015 at 8:20 AM. Resident #1 was asked about the above cited fall and answered with non-sensical words. A face-to-face interview was conducted with Employee #1 on August 24, 2015 at 8:30 AM. Employee #1 was asked about the above incident and stated, I was washing (Resident #1) up for his/her morning care. I turned to the dresser to get the cream for his/her bottom and the next thing I knew he/she was on the floor. He/She was laying on his/her right side and his/her knees were on the bed. He/She doesn ' t move. I guess he/she was over too far. I don ' t really know what happened. It was very fast. A telephone interview was conducted with Employee #2 on August 31, 2015 at 8:45 AM. He/she acknowledged the above findings. The record was reviewed August 24, 2015.

Based on observation, staff interviews and record review for Resident #2, it was determined that facility staff failed to adequately supervise Resident #2 who subsequently sustained a left forehead hematoma. The findings include: Resident #2 was admitted to the facility on [DATE]. According to the Minimum Data Set assessment with an assessment reference date of November 30, 2014, Resident #2 was assessed as having highly impaired vision in Section B (Hearing, Speech and Vision). Resident #2 was assessed with [REDACTED]. Resident #2 was assessed as requiring supervision for walking in the room and corridor, limited assistance with bed mobility and transfers, and extensive assistance with dressing, eating, toileting, personal hygiene and totally dependent for bathing in Section G (Functional Status). Resident #2 was assessed as being unsteady but able to stabilize without staff assistance for turning around and facing the opposite direction while walking in Section G. Disease [DIAGNOSES REDACTED]. Resident #2 was observed on February 24, 2015 at 8:20 AM, 10:00 AM and 1:00 PM. At 8:20 AM, Resident #2 was observed eating breakfast in the dining room. At 10:00 AM, Resident #2 was observed sitting in the resident lounge participating in an activity. At 1:00 PM, Resident #2 was observed sitting in a chair in the dining room, sleeping and difficult to arouse. After several attempts by staff to awaken Resident #2, he/she responded and staff accompanied him/her to his/her room and assisted him/her to the bathroom. Resident #2 appeared clean and well groomed during all the above cited observations. There were no bruised areas on Resident #2 ' s forehead. According to a nurse ' s note dated February 16, 2015 at 15:44 (3:44 PM): " Resident was received this morning wandering in the hallway and was not easily redirected, skin intact, alert and verbally responsive. This writer was notified by the CNA around 12:00 pm that resident has a bump on his/her forehead. Resident was ok 15 minutes prior to the incidence. Upon checking resident was noted with a raised discolored area measured 5 cm x 2.5 cm. No bleeding or any drainage noted. Resident complaining of pain upon touch. Vital Signs (V/S) B/P (blood pressure) 143/82, Pulse (P) 80, Temperature (T) 98.0 Respirations (R) 19, Sp02 - 98% Tylenol 325 mg 2 tablets given for pain. Resident continues to wander in the hallway. CNA was assigned to monitor resident closely. MD was notified around 12:10 PM, an order was given to transfer resident to (Hospital ER) for evaluation but apply ice pack every 15 minutes until 911 arrives ... " According to a nurse ' s note dated February 16, 2015 at 15:37 (3:37 PM): " Resident is alert and responsive, resident return on the unit around 3:25 pm ... Resident refuses vital check. Discharge summary stated he/she was able to eat after his/her injury and is now back to his/her baseline. His/her head injury is most likely superficial. Thus further testing was deferred and resident should be return to the emergency if he/she becomes lethargic, and unable to be aroused or develop nausea/vomiting. Will continue to monitor resident. " Resident #2 sustained a hematoma on the right sided forehead on November 9, 2014. Interventions included: Resident to be supervised by staff at all times. A face-to-face interview was conducted with Employee #1on February 24, 2015 at 8:00 AM. He/she was asked about the above incident and stated, " Resident #2 is very impulsive and difficult to manage. The intervention of always walking him/her wasn ' t realistic. When we talked about Resident #2 in the falls committee meeting we talked about a helmet. I had concerns of dignity with the use of the helmet. I didn ' t do anything else with that. " A face-to-face interview was conducted with Employee #2 on February 24, 2015 at 8:15 AM. He/she was asked about the above concern and stated, " I know that (Resident #2) was harmed. He/she had a hematoma on his/her forehead. It just happened. He/she is blind and I think that he/she walks into door and walls. I talked to (Employee #3) about a helmet but it never went any farther. I forgot to follow-up. " A face-to-face interview was conducted with Employee #3 on February 24, 2015 at 8:30 AM. He/she was asked about the above fall incident and stated, " I didn ' t know that (Resident #2) had another injury that occurred in February (16, 2015). I thought that the interventions we talked about at the falls committee included staff walking with him/her when he/she was walking up and down the halls. I will check into a helmet for Resident #2 today. " At 1:15 PM Employee #3 reported that a wrestler ' s type helmet would be purchased from a local store for temporary use until the helmet from the medical supply company would be delivered in approximately one (1) week. Facility staff failed to adequately supervise Resident #2 who subsequently sustained a hematoma on his/her left forehead. Facility staff was unaware as to how the injury sustained. The record was reviewed February 24, 2015.

Based on observation, record review and staff interview for one (1) of 39 sampled residents, it was determined that facility staff failed to meet professional standards of care as evidenced by not providing life sustaining measures for a resident who was nonresponsive and a full code. Resident #282 The findings include: Facility staff failed to implement life sustaining measures according to accepted standards of clinical practice for Resident #282. According to the "Lippincott ' s Nursing Procedures Fifth Edition " " Code Management Page 467 ... " the goals of any code are to restore the patient's spontaneous heart beat and respirations ... " " Cardiopulmonary Resuscitation Page 474 " Cardiopulmonary Resuscitation (CPR) seeks to restore and maintain the patient's respiration and circulation after his heartbeat and breathing have stopped. Basic life support (BLS) procedures should be performed according to the 2010 American Heart Association (AHA) guidelines. CPR is a BLS procedure that ' s performed on victims of [MEDICAL CONDITION]. Another BLS procedure is clearing the obstructed airway .....Most adults who experience sudden [MEDICAL CONDITION] develop ventricular fibrillation and require defibrillation; CPR alone doesn ' t improve their chances of survival. Therefore, you must assess the victim and then contact emergency medical services (EMS) or call a code before starting CPR. Timing is critical because early access to EMS, early CPR, and early defibrillation greatly improve patient ' s chances of survival. " According to the facility's policy entitled "RN STAT Number 1279 effective date [DATE] Revised date [DATE]" stipulates: " It is the policy of Carroll Manor and Rehabilitation Center to utilize appropriate staff with the most appropriate skill to respond to any urgent resident situation. It is for this reason that " RN STAT " will be announced to call all Clinical Registered Nurses to assist in any urgent resident situation regarding an acute change in a resident ' s health. " ... " See Attachment-Practice Standards. " Practice Standards 1. " RN STAT " is announced in any urgent resident situation regarding an acute change in a resident ' s health. 2. When " RN " STAT is announced all clinical Registered Nurses with-in the building will respond and assist the resident. 3. At least one RN will remain available to assist until the resident situation has been stabilized or the resident is transferred to another setting for assistance. 4. All Registered Nurses are made aware of this practice standard during their orientation and probationary period. " Clinical Record Review: According to the " Admission and Annual Physical Exam Form " dated [DATE] in the section named " Advance Directive " " Full Code " was written. The resident ' s [DIAGNOSES REDACTED]. A review of the resident's Physician order [REDACTED]. A review of the Social Services Assessment and progress note dated [DATE] revealed the resident had " no advance directives " and further states " (Resident ' s Name) CODE STATUS IS FULL CODE. " A review of the nursing documentation in the " Progress Notes by Resident, " dated and timed [DATE] at 06:26 AM revealed the following: " Reported by assigned certified nursing assistant (CNA) while doing (his/her) rounds that (Resident ' s Name) was not breathing Nsg sup (Nursing Supervisor) made aware and is on the unit no palpable B/P (blood pressure) or pulse found PMD (Primary Medical Doctor) on call (Physician ' s Name) made aware and will make (his/her) family aware. " " At around 06:19 AM, this writer was notified that resident was unresponsive, upon arrival to (his/her) room at around 06:20 AM, resident was observed unresponsive, no pulse, no respiration, unable to obtain B/P, body was warm, Resident was a full code. (Physician ' s Name) on call doctor for (Medical Director ' s Name) was notified at around 06:22 AM; MD stated (he/she) will notify family...(Physician ' s Name) gave order that two license nurses may pronounce the body at 06:25 AM. " A review of the care plan updated [DATE] revealed : Advance Directive " Resident and family has requested CPR. Resident wishes will be respected in the event of a medical emergency ". The clinical record lacked evidence that the resident ' s wishes for life sustaining measures were initiated in accordance with the advance directive of the full code status. A face-to-face interview was conducted with Employee #8 on [DATE] at approximately 08:00 AM. When queried about the events that occurred on [DATE] regarding Resident #282, Employee #8 stated the following; " On [DATE] at between 6:25AM and 6:30AM, the CNA assigned to Resident #282 approached me while I was giving medications and stated I think Resident #282 is dead. I immediately went to check the resident ' s code status which revealed(he/she)was a full code. The CNA and I both returned to Resident #282 ' s room. After checking the resident, I detected that (he/she) had no pulse, respiration or b/p (blood pressure). I then proceeded to call the nursing supervisor assigned to the unit. Employee #11 responded immediately. I told (him/her) Resident #282 had no palpable vital signs. We both went back to the resident ' s room. The supervisor stated " The resident had already died and (he/she) was going to call the doctor and inform (him/her) about the resident ' s death. In the process of calling, the second supervisor came on the unit and was informed about what was going on with Resident # 282. The second Supervisor went to the resident ' s room and then came back and said, " Yes (he/she) has already died so don ' t call 911. They will get mad if you do " .( He/she) left the unit. The resident ' s body was warm to touch and not stiff. " When queried regarding the reason CPR was not started or EMS was not activated, (he/she) stated, " I don ' t know why. I figured (he/she) was already dead " . A face-to-face interview was conducted with Employee #13 on [DATE] at approximately 08:20 AM. When queried about the events that occurred on [DATE] regarding Resident #282 (he/she) stated the following; " When I did my rounds at 5:00 AM, Resident #282 was still breathing. The next time I saw (him/ her) around 6:25 AM, the first thing I noticed as I entered the room was a smell like (he/she) had had a bm (bowel movement). Resident #282 was lying on (his/her) side. I touched (him/her) and called out (his/her) name. There was no response, so I checked for breathing and a pulse. There was no pulse and breathing. That ' s when I called the charge nurse, Employee #8 who came right away and told me the resident was a full code. Then (he/she) checked the residents blood pressure and for a pulse and breathing. Then Employee #8 told me to wash and clean Resident #282, and Employee #8 left the room. " A face-to-face interview was conducted with Employee #11 on [DATE] at approximately 08:45 AM. When queried about the events that occurred on [DATE] regarding Resident #282, (he/she) stated the following; " On [DATE] at around 6:20 AM, I received a called from Employee #8 the charge nurse on the first floor unit. (He/she) stated that a resident had expired. " " Upon my arrival to the unit, I said we need to initiate CPR and call 911. The charge nurse said oh no, 911 will be upset for calling them if someone is already dead. I went into the resident ' s room. (He/she) did not have a pulse and was not breathing. There was no blood pressure and the body was stiff. The second supervisor on duty arrived and I informed (him/her) the resident who was a full code had expired. " " The supervisor went in the resident ' s room. When (he/she) came out, (he/she) saw me on the phone and said, I hope you ' re not calling 911 because we don ' t call 911 for situations like this. (He/she) is already dead. I was on the phone notifying Employee #21 that the resident who was a full code was observed with no respirations, pulse or blood pressure, and that the body was stiff. I requested an order for [REDACTED]. Employee #21 called the unit again after, speaking to Resident #282 ' s family to give the charge nurse an order for [REDACTED]. When further queried regarding the reason CPR was not initiated or EMS activated (he/she) stated " I don ' t know why I didn ' t call. I knew it should have been done but everyone said (he/she) was already dead and EMS would be mad if I called for someone that is already dead, so I didn ' t call." A face-to-face interview was conducted with Employee #12 on [DATE] at approximately 10:30 AM. When queried about the events that occurred on [DATE] regarding Resident #282 (she/he) stated the following; " Between 6:30AM and 6:40AM, I went to the first floor unit to collect the twenty four (24) hour report. In the charting room, I met Employee ' s #8 and #11. They informed me that a resident who was a full code had just expired. I went to the room and looked at the resident. The CNA was there. Afterward I picked up the 24 hour report and left the unit. " When further queried regarding the reason CPR was not initiated or EMS activated (he/she) stated, " They said (he/she) was already dead and I did not question it. " A telephone interview was conducted with Employee #21 at approximately 10:00 AM on [DATE]. When queried about the events that occurred on [DATE] regarding Resident #282, (he/she) stated the following; " At approximately 6:40 AM on [DATE], the nursing supervisor called to inform me that Resident #282 had expired, and the family needed to be notified. The supervisor also requested an order for [REDACTED]. At that time I gave an order for [REDACTED]. When queried regarding the resident ' s code status, Employee #21 stated; " They did inform me that the resident had expired, but there was no discussion about the resident ' s code status. I was not familiar with Resident #282, as I was serving in an on call capacity for the Medical Director." There was no evidence the facility staff followed acceptable standards of clinical practice by implementing life sustaining measures in accordance with the advance directive of the full code status when Resident # 282 was nonresponsive. Facility staff failed to implement life sustaining interventions for Resident #282 whose status was designated as a full code. The findings were acknowledged by Employee #2 on [DATE]. The medical record was reviewed [DATE]. Cross referenced to 483.25(h)

Based on observations, record review and interviews, for one (1) of 39 sampled residents, it was determined that facility staff failed to provide life sustaining measures for a resident who was nonresponsive and was a full code. Resident #282. The findings include: Facility staff failed to implement life sustaining measures for Resident #282 who was nonresponsive and had a full code status. According to the "Lippincott ' s Nursing Procedures Fifth Edition " " Code Management Page 467 ... " the goals of any code are to restore the patient's spontaneous heart beat and respirations ... " " Cardiopulmonary Resuscitation Page 474 " Cardiopulmonary Resuscitation (CPR) seeks to restore and maintain the patient's respiration and circulation after his heartbeat and breathing have stopped. Basic life support (BLS) procedures should be performed according to the 2010 American Heart Association (AHA) guidelines. CPR is a BLS procedure that ' s performed on victims of [MEDICAL CONDITION]. Another BLS procedure is clearing the obstructed airway .....Most adults who experience sudden [MEDICAL CONDITION] develop ventricular fibrillation and require defibrillation; CPR alone doesn ' t improve their chances of survival. Therefore, you must assess the victim and then contact emergency medical services (EMS) or call a code before starting CPR. Timing is critical because early access to EMS, early CPR, and early defibrillation greatly improve patient ' s chances of survival. " According to the facility policy entitled "RN STAT Number 1279 effective date [DATE] Revised date [DATE]" stipulates: " It is the policy of Carroll Manor and Rehabilitation Center to utilize appropriate staff with the most appropriate skill to respond to any urgent resident situation. It is for this reason that " RN STAT " will be announced to call all Clinical Registered Nurses to assist in any urgent resident situation regarding an acute change in a resident ' s health. " ... " See Attachment-Practice Standards. " Practice Standards 1. " RN STAT " is announced in any urgent resident situation regarding an acute change in a resident ' s health. 2. When " RN " STAT is announced all clinical Registered Nurses with-in the building will respond and assist the resident. 3. At least one (1) RN will remain available to assist until the resident situation has been stabilized or the resident is transferred to another setting for assistance. 4. All Registered Nurses are made aware of this practice standard during their orientation and probationary period. " Clinical Record Review: According to the " Admission and Annual Physical Exam Form " dated [DATE] in the section named " Advance Directive " " Full Code " was written. The resident ' s [DIAGNOSES REDACTED]. A review of the resident's Physician order [REDACTED]. A review of the Social Services Assessment and progress note dated [DATE] revealed the resident had " no advance directives"and further states " (Resident ' s Name) CODE STATUS IS FULL CODE. " A review of the nursing documentation in the " Progress Notes by Resident, " dated and timed [DATE] at 06:26 AM revealed the following: " Reported by assigned certified nursing assistant (CNA) while doing (his/her) rounds that (Resident ' s Name) was not breathing Nsg sup (Nursing Supervisor) made aware and is on the unit no palpable B/P (blood pressure) or pulse found PMD (Primary Medical Doctor) on call (Physician ' s Name) made aware and will make ( his/her) family aware. " " At around 06:19 AM, this writer was notified that resident was unresponsive, upon arrival to (his/her) room at around 06:20 AM, resident was observed unresponsive, no pulse, no respiration, unable to obtain B/P, body was warm, Resident was a full code. (Physician ' s Name) on call doctor for (Medical Director's Name) was notified at around 06:22 AM; MD stated (he/she) will notify family...(Physician ' s Name) gave order that two (2) license nurses may pronounce the body at 06:25 AM. " A review of the care plan updated [DATE] revealed; Advance Directive " Resident and family has requested CPR. Resident wishes will be respected in the event of a medical emergency. " The clinical record lacked evidence that after the staff was made aware and assessed the resident for responsiveness the resident ' s wishes for life sustain measures were initiated in congruence with the advance directive of Full Code status. Additionally, the record lacked evidence that CPR (Cardiopulmonary Resuscitation) was initialed and the EMS (Emergency Medical System) was activated. A face-to-face interview was conducted with Employee #8 on [DATE] at approximately 08:00 AM. When queried about the events that occurred on [DATE] regarding Resident #282, Employee #8 stated the following; " On [DATE] at between 6:25AM and 6:30AM, the CNA assigned to Resident #282 approached me while I was giving medications and stated I think Resident #282 is dead. I immediately went to check the resident ' s code status which revealed (he/she)was a full code. The CNA and I both returned to Resident #282 ' s room. After checking the resident, I detected that (he/she) had no pulse, respiration or b/p (blood pressure). I then proceeded to call the nursing supervisor assigned to the unit. Employee #11 responded immediately. I told (him/her) Resident #282 had no palpable vital signs. We both went back to the resident ' s room. The supervisor stated " The resident had already died and (he/she) was going to call the doctor and inform (him/her) about the resident ' s death. In the process of calling, the second supervisor came on the unit and was informed about what was going on with Resident # 282. The second Supervisor went to the resident ' s room and then came back and said, " Yes (he/she) has already died so don ' t call 911. They will get mad if you do " .( He/she) left the unit. The resident ' s body was warm to touch and not stiff. " When queried regarding the reason CPR was not started or EMS was not activated, (he/she) stated, " I don ' t know why. I figured (he/she) was already dead " . A face-to-face interview was conducted with Employee #13 on [DATE] at approximately 08:20 AM. When queried about the events that occurred on [DATE] regarding Resident #282 he/she stated the following; " When I did my rounds at 5:00 AM, Resident #282 was still breathing. The next time I saw (him/ her) around 6:25 AM, the first thing I noticed as I entered the room was a smell like (he/she) had had a bm (bowel movement). Resident #282 was lying on (his/her) side. I touched (him/her) and called out (his/her) name. There was no response, so I checked for breathing and a pulse. There was no pulse and breathing. That ' s when I called the charge nurse, Employee #8 who came right away and told me the resident was a full code. Then (he/she) checked the residents blood pressure and for a pulse and breathing. Then Employee #8 told me to wash and clean Resident #282, and Employee #8 left the room. " A face-to-face interview was conducted with Employee #11 on [DATE] at approximately 08:45 AM. When queried about the events that occurred on [DATE] regarding Resident #282, he/she stated the following; " On [DATE] at around 6:20 AM, I received a called from Employee #8 the charge nurse on the first floor unit. (He/she) stated that a resident had expired. " " Upon my arrival to the unit, I said we need to initiate CPR and call 911. The charge nurse said oh no, 911 will be upset for calling them if someone is already dead. I went into the resident ' s room. (He/she) did not have a pulse and was not breathing. There was no blood pressure and the body was stiff. The second supervisor on duty arrived and I informed (him/her) the resident who was a full code had expired. " " The supervisor went in the resident ' s room. When (he/she) came out, (he/she) saw me on the phone and said, I hope you ' re not calling 911 because we don ' t call 911 for situations like this. (He/she) is already dead. I was on the phone notifying Employee #21 that the resident who was a full code was observed with no respirations, pulse or blood pressure, and that the body was stiff. I requested an order for [REDACTED]. Employee #21 called the unit again after, speaking to Resident #282 ' s family to give the charge nurse an order for [REDACTED]. When further queried regarding the reason CPR was not initiated or EMS activated (he/she) stated " I don ' t know why I didn't call. I knew it should have been done but everyone said (he/she) was already dead and EMS would be mad if I called for someone that is already dead, so I didn't call." A face-to-face interview was conducted with Employee #12 on [DATE] at approximately 10:30 AM. When queried about the events that occurred on [DATE] regarding Resident #282 (she/he) stated the following; " Between 6:30AM and 6:40AM, I went to the first floor unit to collect the twenty four (24) hour report. In the charting room, I met Employee ' s #8 and #11. They informed me that a resident who was a full code had just expired. I went to the room and looked at the resident. The CNA was there. Afterward I picked up the 24 hour report and left the unit. " When further queried regarding the reason CPR was not initiated or EMS activated (he/she) stated, " That (he/she) was already dead and I did not question it. " A telephone interview was conducted with Employee #21 at approximately 10:00 AM on [DATE]. When queried about the events that occurred on [DATE] regarding Resident #282, he/she stated the following; " At approximately 6:40 AM on [DATE], the nursing supervisor called to inform (him/her) that Resident #282 had expired, and the family needed to be notified. The supervisor also requested an order for [REDACTED]. At that time I gave an order for [REDACTED]. When queried regarding the resident ' s code status, Employee #21 stated; " They did inform me that the resident had expired, but there was no discussion about the resident ' s code status. I was not familiar with Resident #282, as I was serving in an on call capacity for the Medical Director." Facility staff failed to implement life sustaining interventions for Resident #282 whose status was designated as a full code. The findings were acknowledged by Employee #2 on [DATE]. The medical record was reviewed on [DATE]. Cross referenced to 483.25(h)

Based on record review and staff interview for three (3) of 33 sampled residents, it was determined that facility staff failed to ensure that Resident #3, who had an alteration in skin integrity, classified by the facility as a " denuded " area to the coccyx (November 11, 2011) received necessary treatment and services in a timely manner to promote healing; Subsequently on March 1, 2012 the wound progressed to an Unstageable pressure ulcer. Additionally, facility staff failed to consistently assess the characteristics and monitor the progression of pressure sores for two (2) other residents. Residents #3, #16 and #289. The findings include: 1.Facility staff failed to ensure that Resident #3, who had an alteration in skin integrity, classified by the facility as a " denuded " area to the coccyx (11/11/11). The area progressed to "Unable to accurately Stage" (according to the facility's documentation) on March 1, 2012. There was no evidence that facility staff consistently provided necessary treatment and services to promote wound healing. Subsequently, the wound progressed to an Unstageable pressure ulcer. According to the facility ' s policy entitled; " Pressure Ulcer Management; Policy No: 1215; Revised Date: 08/10/12 " stipulated the following: " II. Procedure: 2. Weekly rounds are made on residents with new or difficult to manage pressure areas. On these rounds, the present treatment modality is evaluated for effectiveness. Changes in treatment may be suggested at this time. 5. Wound care Nurse or designee will observe application of dressings to ensure proper technique. 6. The CNA (Certified Nursing Assistant) will report any changes in the skin and turn in the report to their Team Leader that shift. The Team Leader will observe the skin, document wound status, treatment and measurement on the Skin and Wound update section of the EMR (Electronic Medical Record), and notify the Nurse Manager/Designee or Supervisor for that shift of the changes. 7. The Team Leader will follow up the physician for orders as needed and notify the responsible party; and 9. The Nurse Manager/Designee will make weekly skin assessment rounds and the RN (Registered Nurse) will ensure that the wound status, treatment and measurements on the " Skin and Wound " section on the EMR is correct. " Denuded skin is defined by a John Hopkins; " Wound Care Assessment and Documentation Treatment " slide presentation on February 18, 2011 as " Loss of superficial epidermis. " www.slideshare.net/nektovaleri/wound-care- 23. According to the quarterly MDS dated [DATE] revealed that Resident #3 was coded for requiring extensive assistance in Bed Mobility, Transferring, Dressing, Toileting, Personal Hygiene under Section G (Functional Status); Section H (Bladder and Bowel) the resident was coded, Urinary and Bowel as always incontinent; and Section M (Skin Conditions) was coded as at risk of developing pressure ulcers and Section M was coded as none of the above for the presence of Skin impairment of any type. Section I the resident ' s [DIAGNOSES REDACTED]. The annual MDS dated [DATE] revealed that Resident #3 was coded for requiring extensive assistance in Bed Mobility, Dressing, Personal Hygiene and total dependence in transferring, and toileting under Section G (Functional Status); Section H (Bladder and Bowel) the resident was coded, Urinary as always incontinent and frequently incontinent of Bowel; and Section M (Skin Conditions)-M0150 was coded as at risk of developing pressure ulcers and M1040 was coded as none of the above were present. However, the resident had alteration in skin integrity to his/her coccyx. The care plan entitled, " Problem #41, Hx (history) of Interruption in Skin Integrity " initiated 01/24/11 revealed, and " Goal-wound will be free of infection and healing gradually within 90 days. Approach: ...1. Turn and position every 2 hours. 2. Measure and document size of wound. 3. Reassess wound every 7 days and PRN. 4. Notify Wound nurse of new wound. 5. Treat wound as ordered ... " On 11/11/11 the care plan was updated to included " Interruption in Skin Integrity related to Coccyx area " . At this time facility staff failed to provide a written description of the wound on the care plan. On February 29, 2012 the care plan was updated to include, " wound nurse staged coccyx ulcer as Stage 3 " On March 1, 2012 the care plan was updated to include, " Coccyx ulcer unstageable " Braden Scale or Predicting Pressure Sore Risk dated October 17, 2011=14 mod (moderate) risk; 13-14= moderate risk. For scores below 18 institute Carroll Manor Pressure Ulcer Prevention Protocol Laboratory Results- A review of the laboratory results dated [DATE] revealed that Resident #3 ' s [MEDICATION NAME] level was 3.0 Low, reference range 3.2-5.0g/dl. The laboratory results dated [DATE] revealed that the [MEDICATION NAME] level was 2.6 Low (range 3.2-5.0). Physician ' s Interim Orders " November 11, 2011 at 2035 ...Clean open pink on coccyx area with Bedside Care Foam (Bedside Care Foam) and pat dry. Apply [MEDICATION NAME] Ointment (multipurpose skin barrier cream) twice daily x (times) 14 days ... " " November 29, 2011 at 1030 ...Clean denuded area on the Coccyx with Bedside Care Foam, apply Saf-Gel (Hydrating Dermal Wound Dressing), cover with 4x4 gauze and secure with [MEDICATION NAME] (Transparent Film Dressing). Change dsg (dressing) daily x 14 days. D.C. (discontinue) [MEDICATION NAME] Ointment to Coccyx open area ... " " December 7, 2011 at 1123 ...Cleanse denuded area on the Coccyx with Bedside Care Foam, apply [MEDICATION NAME] Sacral Boarder (an all-in-one foam dressing that effectively absorbs and retains exudate and maintains a moist wound environment). Change every 3 days and PRN. D.C Saf-Gel dsg to Coccyx. " " December 28, 2011 at 1100 ... Cleanse denuded areas on the Sacro-Coccyx area with Bedside Care Foam, apply Stomadhesive powder (Helps form a protective barrier for excoriated or weeping skin) and [MEDICATION NAME] and Baza Clear (aids in the treatment & prevention of diaper [MEDICAL CONDITION] & protects skin from wetness and moisture), apply BID (twice daily). D.C. Rx (medical prescription) with [MEDICATION NAME] Border ... " " December 30, 2011 at 1430 ...Vitamin C 500mg by mouth twice daily for wound healing x 14 days. Zinc [MEDICATION NAME] 220mg by mouth daily for wound healing x 14 days ... " " February 7, 2012 at 1100 ...Sacro-Coccyx Ulcer: Cleanse with normal saline, apply Santyl Ointment (a sterile enzymatic [MEDICATION NAME] ointment which contains 250 [MEDICATION NAME] units per gram of white [MEDICATION NAME] USP), cover with 4x4 gauze; Secure with [MEDICATION NAME]. Change dsg daily x 14 days. Keep the heels floated while in bed with the help of pillows ... " " February 15, 2012 at 1710 ...Increase Ensure to TID (three times a day) (Provides 1050 Kcal, 39 g protein). Give Zinc Sulfate 220mg p.o. daily x 14 day(s) for wound. Give Vitamin C 500 mg p.o. daily for wound x 14 days ... " " February 22, 2012 at 1040 ...D.C. previous Rx order dated 2/15/2012. Cleanse Sacro-Coccyx Ulcer with Normal Saline. Fill the wound bed with 2x2 gauze saturated with ?th strength Dakin's Solution (antiseptic solution containing sodium hypochlorite and developed to treat infected wounds). Cover with 4x4 gauze, secure with tape. Change dsg Q (every) shift/PRN x 7 days. " " February 28 (2012) at 1300 ...D.C. previous Rx order for Sacro-Coccyx Ulcer dated 2/22/12. Cleanse Sacro-Coccyx Ulcer with Normal Saline; apply/sprinkle [MEDICATION NAME] pwd (powder). Fill the wound with gauze saturated with Santyl Ointment. Cover with 4x4 gauze, secure with [MEDICATION NAME]. Change dsg daily x 21 days. " A review of the Treatment Administration Records (TAR) revealed: According to the TAR the resident received [MEDICATION NAME] Ointment as ordered from November 11 - 25, 2011. It was noted that treatment/dressing change on November 25, 2011 (the second dressing) and November 26, 27 and 28, 2011 were blank indicating (that the treatment was not signed as being done). The resident received Bedside Care Foam with Mexiplex Sacral Border as ordered on December 10, 14, 17, 19, 21, 24, 26, and 28, 2011. It was noted that treatment/dressing change on December 8 and 9, 2011 were blank indicating (that the treatment was not signed as being done). According to the documentation on the TAR, February 16 thru 22 and 29, 2012 the resident received a treatment to cleanse Sacro-Coccyx ulcer with Normal Saline, sprinkle [MEDICATION NAME] powder; apply pack 2x2 gauze saturated with poly Santyl ointment, cover with 4x4 gauze; secure with Tegadem. However, there is no documented evidence of a physician's order [REDACTED]. In summary, there was no evidence that facility staff administered the wound treatment in accordance with the physician's order [REDACTED]. Additionally, from February 16 thru 22, 2012 facility staff conducted a wound treatment to the resident ' s sacro-coccyx in the absence of a physician's order [REDACTED]. Skin Condition Report -Unhealed Daily Wound Assessment revealed: " 11/11/2011 Present on the Coccyx is a denuded area. The following findings were documented, length in cm=0.8, width in cm=0.5, no odor is present, no drainage is apparent, recent changes were made to the treatment orders for this site, no itching or discomfort, General comments: At 2020 reported by CNA resident noted open pink area on coccyx measuring 0.8cm x 0.5cm, (physician) notified and gave order to clean the area with bedside care foam and pat dry, apply [MEDICATION NAME] ointment twice daily x14 days. " " 11/15/2011 Present on the Coccyx is a denuded area: The following findings were documented, General comments: Resident denuded area on coccyx assessed this morning, area measures 0.5 x 0.5 appearance is pink, no drainage noted. Treatment continues to cleanse with bedside foam and apply [MEDICATION NAME] bid x14 days. " " 11/23/2011 Present on the Coccyx is a denuded area: The following findings were documented, Length 0.2 x width 0.2, skin is not blanchable, no odor is apparent, no drainage is apparent, This wound was not present on admission, wound baseline visible, pink wound base = 100%, granulation tissue type = 100%, no itching, or discomfort, condition is flat, color is pink, wound has no pattern -scattered, no foreign bodies , surrounding tissues is normal, The affected area has an absence of hair, skin tissue temperature is warm to touch, margins are regular, resident has no pain. Skin turgor is fair, General comments: Denuded area on coccyx healing well, site dry and pink in color, site improvement noted. " " 11/24/11 Present on the coccyx is a denuded area. The following findings were documented, PA, NP, MD were notified of the present status of site. No changes in site condition, no recent changes were made to the treatment orders for this site, antibiotics are not currently in use. General Comments: Open area on coccyx assessed, cleanse with bedside foam as ordered and [MEDICATION NAME] applied to site, no bleeding or odor at site. " " 11/28/2011 Present on the coccyx is a denuded area. The following findings were documented Length in cm=0.5, width in cm=0.5, depth in cm= 0, no odor is apparent, no drainage is apparent recent changes were made to the treatment orders for this site, the wound was not present on admission, General comment: pale pink dry wound bed, also noted moist areas in the gluteal fold and in the periwound area, current applying Safgel ointment and covering with gauze and [MEDICATION NAME], change dressing daily14 days, wound base is visible, pink wound base = 100%, condition is flat, color pink, no foreign bodies present, surrounding tissue hyper pigmented, skin tissue temperature is consistent with surrounding tissue, margins are regular, mucus membranes are dry, mucus membranes are pink, skin turgor is fair, no change in site condition, recent changes were made to the treatment orders for this site, Antibiotics are not currently in use: pressure reducing or relieving devices are in place, devices used on the bed surface, extremity device or shoes used, turning and repositioning program being implemented. Nutrition update: protein supplemental administered other nutritional programs in Ensure. Risk factor: Decreased mobility, inactivity. " " 11/29/2011 Present on the coccyx is a denuded area. The following findings were documented General comments: Residents Coccyx area assessed this morning is pink and dry and new treatment orders received to cleanse with bedside foam and apply Safgel daily, no pain at site. " " 12/07/2011 Present on the coccyx is a denuded area. The following findings were documented Length in cm=0.5, width in cm=0.5, depth in cm=0, no odor is apparent, no drainage is apparent, The wound was not present on admission, General comments: dark pink wound bed with very scant drainage, recommend applying [MEDICATION NAME] sacral border to the dressing, wound base is visible, pink wound base = 100%, no foreign bodies present, surrounding tissue is normal, skin tissue temperature is consistent with surrounding tissue, margins are irregular, mucus membranes are moist, mucus membranes are pink, skin turgor is fair ... " " 12/13/2011 Present on the coccyx is a denuded area. The following findings were documented General comments: Sacral coccyx area assessed this shift and appearance pink and moist, treatment done as ordered with [MEDICATION NAME] sacral border, no drainage was noted, no odor " " 12/14/2011 Present on the coccyx is a denuded area: Length 0.5cm x width 0.5cm, skin is not blanchable, no drainage, wound base is visible, pink wound base = 100%. " " 12/21/2011 Present on the coccyx is a denuded area: Length 1cm x width 1cm, depth 0.1cm, drainage consistency is thin, scant drainage is present, color is clear, red area on the edges with pale pink area in the center, wound base is visible, pink wound base = 15%, red wound base = 85%, surrounding tissue is moist, continue applying [MEDICATION NAME] sacral dressing. " " 12/27/2011 Present on the coccyx is a denuded area.: Length 0.5cm x width 0.3cm, depth 0cm, skin is blanchable, no odor, no drainage, red in color, is red and moist, treatment cleanse with bedside foam and with [MEDICATION NAME] sacral border every third day. " " 12/28/2011 Present on the coccyx is a denuded area.: Length 3cm x width 6cm, depth 0cm, drainage consistency is thin, scant drainage is present, color is clear, denuded superficial dark pink ... with irregular borders, wound base visible, red wound base = 100%, Apply Stomadhesive powder, [MEDICATION NAME] and baza clear as moisture barrier ointment, Nutrition: zinc and vitamin C, protein supplement. " " 01/06/2012 Present on the coccyx is a denuded area ...Length 2cm x width 4.5cm. depth 0cm, no drainage , wound base visible, red wound base = 100%, [MEDICATION NAME] tissue type =100%, wound red, margins are irregular, treatment no changes, continue pressure reducing or relieving devices, Nutrition zinc, vitamin C and protein supplement. " " 01/09/2012 Present on the coccyx is a denuded area.: Length 2cm x width 4cm, depth 0cm, no odor, no drainage, wound base visible, red wound base = 100%, [MEDICATION NAME] tissue type =100%, wound red, margins are irregular, treatment no changes, continue pressure reducing or relieving devices, Nutrition Zinc, Vitamin C. " " 01/17/2012 Present on the coccyx is a denuded area ... Length 1.5cm x width 0.8cm, depth 0cm, wound base visible, red wound base = 100%, [MEDICATION NAME] tissue type =100%, wound red, margins are irregular, treatment no changes, continue pressure reducing or relieving devices, Nutrition zinc, vitamin C and protein supplement. " " 01/23/2012 Present on the coccyx is a denuded area ...no measurements, drainage consistency is thin, minimal drainage is present, color is red-tinged, noted in the center mildly ecchymotic area, Denuded area from tape toward distal area, wound base visible, red wound base = 100%, surrounding tissue is macerated, margins are irregular, treatment no changes, continue pressure reducing or relieving devices are in place, turning and repositioning program implemented. " " 01/24/2012 Present on the coccyx is a denuded area. The following findings were documented, length in cm = 3.5, width in cm=1.5, no odor is apparent, drainage consistency is thin, minimal drainage is present, color ids red-tinged. The wound was not present on admission. Wound base is visible, Red wound base=100% , [MEDICATION NAME] tissue type=100%, no itching or discomfort, condition is flat, color is bright red, no foreign bodies present, surrounding tissue is macerated, skin tissue temperature is warm to touch, margins are irregular, mucous membranes are moist, mucus membranes are pink, Skin turgor is fair, skin tear flap edges are open, site improvement noted , no recent changes were made to the treatment orders for this site. " " 01/31/2012 Present on the coccyx is a denuded area... The following findings were documented, length in cm = 4, width in cm=2, no odor is apparent, no drainage is apparent, this wound was not present on admission, wound base is visible, red wound base=100% , [MEDICATION NAME] tissue type =100%, no itching or discomfort, condition flat, color is red, no foreign bodies present, skin tissue temperature is warm to touch, margins are irregular, resident has no pain, skin turgor is fair, deterioration noted in site, risk factors; General comment: resident wound site worsening, red in color , no odor, no drainage noted. Wound nurse made aware. [MEDICATION NAME] treatment continues as ordered. " " 02/07/2012 Present on the coccyx is a denuded area. The following findings were documented, length in cm = 3.5, width in cm=3.5, Depth in cm=0.2, no odor is apparent, drainage consistency is thin, minimal drainage is present, color is red tinged, this wound was not present on admission, General comments: Noted dark pink area around the edges, with mild pale yellow area in the center, would recommend the application of Santyl. Wound base is visible, red wound base= 70%, yellow wound base=30%, no foreign bodies present, surrounding tissue is normal. The affected area has an absence of hair, skin tissue temperature is consistent with surrounding tissue, and margins are irregular, resident has no pain, mucus membranes are moist, skin turgor is fair, deterioration noted in site. " " 02/14/2012 Present on the coccyx is a denuded area. The following findings were documented, length in cm = 3.2, width in cm=2, no odor is apparent, drainage consistency is thin, scant drainage is present, color is tan, Wound base is visible, pink wound base= 60%, red wound base =20%, yellow wound base=20%, [MEDICATION NAME] tissue type = 100%, no foreign bodies present, surrounding tissue is normal. Skin tissue temperature is consistent with surrounding tissue, margins are irregular, mucus membranes are moist, mucus membranes are pink, skin turgor is fair. " " 02/15/2012 Present on the coccyx is a denuded area. The following findings were documented, length in cm = 3.5, width in cm=2, depth in cm =0.5, no odor is apparent, drainage consistency is thin, minimal drainage is present, color is red-tinged, recent changes were made to the treatment orders for this site, This wound was not present on admission, General comments: The wound appears reddened with brown colored non-viable tissue, minimal drainage. Recommend applying 2 x 2 gauze saturated with Santyl deterioration noted in site. " " 02/21/2012 Present on the coccyx is a denuded area. The following findings were documented, length in cm = 2.5, width in cm=2.0, Skin is not blanchable, drainage consistency is thin, scant drainage is present, color is red-tinged, This wound was not present on admission, General comments: sacral-coccyx ulcer treatment done as per order to sprinkle [MEDICATION NAME] powder and packaging done with 4x4 gauze with [MEDICATION NAME] powder Santyl ointment and secured with [MEDICATION NAME]. Resident is also on Zinc [MEDICATION NAME] and Vitamin C for wound healing. " " 2/22/2012 - Present on the Coccyx is a DENUDED AREA. The following findings were documented; Length in cm = 3.5, Width in cm = 2.5, Depth in cm = 0.8, no odor is apparent, drainage consistency is thin, minimal drainage is present, color is red-tinged. Recent changes were made to the treatment orders for this site. This wound was not present on admission. General Comments: Noted (approximately) 10% of loose pale brown slough, with pale red wound base. Minimal serosangious drainage; mildly ecchymotic around the edges. Recommend application of 2 X 2 gauze saturated with Dakin ' s solution to fill the wound bed. Wound initially appeared as denuded area moisture contributing to the formation of the ulcer. Appearance now suggest the role pressure also involved leading to the current status of the wound. Wound base is visible, Red wound base = 90%, yellow wound base = 10%, Granulation tissue type = 90%, Slough tissue type = 10%. Recent changes were made to the treatment order for this site, antibiotics are not currently in use; pressure reducing or relieving device (s) are in place, devices used on the bed surface, extremity device or shoe used, turning and repositioning program being implemented. Nutritional update, protein supplement administered, Vitamin C administered, Zinc administered, other nutritional programs in ensure plus. Risk Factors; Co-Morbidities, Decreased Mobility. " " 2/22/2012 - Skin and Wound Update to Site- 352. Present on the Coccyx is a DENUDED AREA. The following findings were documented, General Comments: dietician made aware for the inclusion of Vitamin C and Zinc. " " 2/28/12- Skin and Wound Update to Site -352, Condition changed (From: DENUDED AREA To: Pressure Area). Reason: wound appearance is chronic and has progressed to this stage suggests pressure was the (major) contributing factor in addition to (moisture), shear and friction. Present on the Coccyx is a Pressure Ulcer. The following findings were documented: Staging, Stage3, Length in cm = 2, Width in cm = 2, Depth in cm= 1, no odor is apparent; drainage consistency is thick, minimal drainage is present, color is red-tinged, color is serosanguinous. Recent changes were made to the treatment orders for this site. General Comments: Noted that the wound has progressed from Stage II to Stage III. Wound was identified as denuded area, which in fact was a Stage II ulcer, slowly progressed now to the current stage. Wound base is visible, Pink wound base = 10%, Red wound base = 40%, Black Brown Base = 50%; no foreign bodies present, surrounding tissue is macerated, surround tissue is hyper pigmented. Skin tissue temperature is consistent with surrounding tissue; margins are irregular; mucous membranes are moist. Skin Turgor is fair. Pressure reducing or relieving devices (s) are in place, devices used on the bed surface, turning and repositioning program being implemented. Nutritional update; protein supplement administered, Vitamin C administered, Zinc administered, other nutritional programs in ensure, Risk Factors: Co-Morbidities, Decreased Nutrition. " " 2/29/2012 - Skin and wound update to Site- 352. Present on the Coccyx is a Pressure Ulcer. The following findings were documented: Staging, Stage 3, Length in cm = 2, Width in cm = 2, Depth in cm = 1; a faint odor is apparent, drainage consistency is thin, moderate drainage is present, color is serosanguineous. Recent changes were made to the treatment orders for this site. Wound base is visible; Red wound base = 60%, Black Brown base = 40%, Granulation tissue type = 50%; Slough tissue type = 50%. Surrounding tissue is macerated, surrounding tissue is firm, skin tissue temperature is consistent with surrounding tissue, margins are irregular. Mucous membranes are moist, mucous membranes are pink. Skin turgor is fair. Pressure reducing or relieving device(s) used on the bed surface, turning and repositioning program being implemented. Risk Factors: Co-Morbidities, Decreased Mobility, Decreased Nutrition, PUSH Tool 3.0; Total Score = 11. " " 3/1/12 - Present on the Coccyx is a Pressure Ulcer. Unable to accurately stage- Slough and/or Eschar covered; no drainage is apparent. General Comments: Noted 70-80% dark brown; non-viable tissue noted on the wound bed. Wound had foul odor. Also noted with induration around the lateral edges. Discussed with (MD ' s name) about the current status of the wound condition. (MD ' s name) said he will come and see the wound. Saw the wound again with (MD ' s name). Advised for a surgery consult for possible debridement. Wound base is visible, Red wound base = 20%, Black Brown base= 70%. Other color in wound base = 10%, surrounding tissue is indurated. Skin tissue temperature is consistent with surrounding tissue; margins are irregular, margins are thickened, mucous membranes are moist, mucous membranes are pink. Skin turgor is fair. Pressure reducing or relieving devices (s) are in place. " " 3/9/12-Present on Coccyx is a pressure ulcer. The following were documented, Staging, Stage 4, color is serosanugineous. Recent changes were made to the treatment orders for this site. This wound was not present on admission. Wound base us visible, Red wound base=90%m yellow wound base=10%, Granulation tissue type=90%, slough tissue type=10%, surrounding tissue is macerated ...Risk Factors: PUSH Tool 3.0, Total Score=12 ... " Nutrition According to the clinical record " December 30, 2011 at 1430 ...Vitamin C 500mg by mouth twice daily for wound healing x 14 days. Zinc [MEDICATION NAME] 220 mg by mouth daily for wound healing x 14 days was directed to be given on December 30, 2011. When the skin impairment was first observed there was no evidence that a nutritional assessment was conducted to determine if additional nutritional supplements were necessary to promote the healing of the impaired skin for 45 days. After the assessment was done on December 30, 2011 the resident received the supplements for 14 days (December 31, 2011 - January 13, 2012) at this time the order stopped. A review of the Physician ' s Interim Orders revealed, " February 15, 2012 at 1710 ...Increase Ensure to TID (three times a day) (Provides 1050 Kcal, 39 g protein). Give Zinc Sulfate 220mg p.o. daily x 14 day(s) for wound. Give Vitamin C 500 mg p.o. daily for wound x 14 days ... " There was no evidence that the resident received additional supplementation between January 14, 2012 and February 16, 2012. The Dietitian ' s assessment on February 15, 2012 revealed the following, " ...Intervention #3, " Initiate Vitamin C and Zinc supplementation times 14 days for micronutrient repletion and to promote wound care. " A face-to-face interview was conducted with the Employee # 27on September 24, 2012 at11:26 AM. He/she stated, " We (dietitians) only follow pressure ulcers (Note: the facility characterized Resident#3 ' s wound as a denuded area). When it was documented as a pressure ulcer I put interventions in place. " Physician Review A review of the medical record revealed that the attending physician made a visit on January 5, 2012. There was no evidence that physician addressed the changes in condition to the Resident ' s coccyx in his/her review. A face-to-face interview was conducted with Employee # 4 on September 24, 2012 at approximately 4:45 PM. He/she stated, " The area was very superficial. There was no evidence for me to say it went beyond the dermal layer when it was first observed. It was a denuded area that is what was documented. I treated the area. (He/she) was on an air loss mattress. It was a Stage 2 when I was saying it was denuded. After one month I did not change the diagnosis. It was denuded until February (2012) when it became a Stage 3 and then a Stage 4. " Summary ? According to the aforementioned quarterly and annual MDS and the Braden Scale the resident was at risk for pressure sores. ? There was no evidence that facility staff administered the treatment to the coccyx as per the physician's order [REDACTED]. ? According to the documentation on the TAR, February 16 thru 22 and 29, 2012 the resident received a treatment to cleanse Sacro-Coccyx ulcer with Normal Saline, sprinkle [MEDICATION NAME] powder; apply pack 2x2 gauze saturated with poly Santyl ointment, cover with 4x4 gauze; secure with Tegadem. However, there is no corresponding physician's order [REDACTED]. ? There was no evidence that the resident received additional nutritional supplementation for 30 days (January 14, 2012 and February 16, 2012). ? A review of the medical record revealed that the attending physician made a visit on January 5, 2012. There was no evidence that physician addressed the changes in condition to the Resident ' s coccyx in his/her review. In conclusion there was no evidence that the facility consistently implemented interventions to promote wound healing for the altered skin integrity sustained by Resident #3. The resident sustained [REDACTED]. The site of the wound, the coccyx area, is located at a bony prominence at a pressure point; the resident was assessed as " always incontinent " of bowel and bladder according to the MDS and the facility ' s pressure ulcer risk assessment tool revealed that the resident was a " moderate " risk for pressure ulcers. The facility characterized the altered skin as a " denuded area " although the wound was assessed with [REDACTED]. The dietician was not consulted for greater than 40 days after the wound was initially identified and was noted to have progressed as opposed to improved. The interventions recommended by the dietician for nutritional supplementation for micronutrient repletion and promotion of wound healing were followed for a period of 14 days and discontinued thereafter. The interventions related to nutritional supplementation was absent for a period of approximately 30-days wherein it was determined that the wound significantly deteriorated. There was no evidence the facility staff ensured that Resident #3, who had an alteration in skin integrity, classified by the facility as a " denuded " area to the coccyx, consistently received the necessary treatment and services to promote wound healing. The wound progressed over approximately 3 months to Stage 4 pressure ulcer. According to the Physician ' s Interim orders, dated March 4, 2012 the Resident #3 was transferred to (hospital) for sacral ulcer management. The record was reviewed on September 24, 2012. 2. Facility staff failed to consistently assess the status of skin impairment for Resident #16. Review of the " Progress Notes by Resident " notes dated May 5, 2012 11:23 AM revealed that Resident #16 was admitted to the facility with an alteration in skin integrity of the coccyx. Review of the " Skin Condition Report with Images " sheet dated May 5, 2012 identified the skin alteration as Site 388 which indicated: "New (1st recording) ...cracked opened red areas in between buttocks 1x0.4cm and 2x0.5cm no drainage (no identification of the location on anatomical image)." Further review of the " Skin Condition Report with Images " sheets which identified the skin alteration as Site 388 dated May 9, 2012, May 22, 2012 and May 29, 2012 lacked information about the site in terms of progress of the wound, the description, measurments, or staging or the wound. Review of the " Progress Notes By Residents " dated May 11, 2012 and May 12, 2012 indicated that Baza ointment was applied to buttocks as per Dr. orders, however no measurements, staging or description of the wound was identified. Further review of the " Progress Notes By Residents " dated May 28, 2012 indicated that the resident was discharged to home ..., however no status

Based on observation, staff and resident interviews and record review for one (1) of nine (9) residents, it was determined that facility staff failed to properly position Resident #1 in bed prior to turning. The resident subsequently fell out of bed and sustained a hematoma on the right forehead. The findings include: Resident #1 was born on July 5, 1920 and was admitted to the facility on [DATE]. According to the annual Minimum Data Set (MDS) assessment dated [DATE], Resident #1 scored 15/15 on the Brief Interview for Mental Status. According to the MDS 3.0 User ' s Manual, page C-14, a score of " 13-15 " suggests that the resident is " cognitively intact. " Resident #1 was assessed as being totally dependent for all Activities of Daily Living in Section G (Function Status). Disease [DIAGNOSES REDACTED]. A review of Resident #1 ' s record revealed that his/her last fall was June 26, 2010. The following nurses ' notes were reviewed: March 14, 2012 at 10:30 PM: " It was reported to writer by the CNA that he/she turned resident on his/her left side to give care. Resident suddenly rolled out of bed to the floor on his/her right side. On assessment he/she was noted with a swollen area on his/her right forehead measured 2 cm x 2 cm. Range of motion done to all extremities, it was within normal limits for resident. Vital signs taken, resident alert and responsive, neuro checks done pulse ox done 90% on O2 at 2 liters. Started ice pack. Applied to hematoma, MD called gave order to transfer resident to ER. Resident was transferred to ER via 911 by stretcher. POA notified. " March 15, 2012 at 5:48 AM: " Resident came back from ER at 3:25 AM. He/she is alert and verbally responsive, able to explain what happened. Right side forehead raised area while touching reacted to pain. CT scan of the brain result mild volume loss and small vessel white matter ischemic changes. No fractures. Neuro check continues. V/S (vital signs) 140/68 (Blood Pressures), Temp 97.3?, Pulse 64, Respirations 16. Resident is sleeping easily raisable. No c/o of pain at this moment. " According to the physician ' s note dated March 14, 2012 at 10:45 AM: " Patient had a fall yesterday evening. He/she was transferred to ER. CT of brain and CT of neck were negative. Patient is lethargic now due to pain medications. VS stable, lungs CTA (clear to auscultation), heart S1, S2, RRR (regular rate and rhythm), abd soft and non-tender, neuro lethargic, arousable. A&P: status [REDACTED]. " A face-to-face interview was conducted with Resident #1 on March 22, 2011 at 2:30 PM. He/she was asked about the above incident. Resident #1 stated, " I just fell out of bed. I tried to grab the side rail but I just kept going. I don ' t have control over my feet and my hands aren ' t very strong. " There was no evidence of a hematoma on the resident ' s forehead at the time of this interview. A face-to-face interview was conducted with Employee #1 on March 22, 2012 at 3:15 PM. Employee #1 was caring for Resident #1 when the resident fell out of bed. Employee #1 stated, " I had just finished cleaning Resident #1 up. I went to put his/her diaper on. I rolled him/her to the left side and then he/she rolled over and fell from the knees first and then continued to fall. I couldn ' t control the fall. I have worked with Resident #1 many times before. He/she doesn ' t move on his/her own, he/she is very weak. I turned him/her too much over to the side and didn ' t bring him/her close enough to me. I am really sorry he/she got hurt. " A face-to-face interview was conducted with Employee #2 on March 22, 2012 at 4:00 PM. Employee #2 stated, " Employee #1 had completed his/her competencies in June and October (2011). He/she has had no write-ups in his/her personnel folder. He/she has been a good CNA since he/she was hired in June (2011). He/she used poor judgment. " The record was reviewed March 22, 2012.

A. Based on observations, record and staff interviews, it was determined that the facility staff failed to maintain the dish machine in safe operating condition, as evidenced by failure to ensure that the dish machine maintained an acceptable final rinse temperature (180 degrees Fahrenheit (F)) to sanitize china/dishware and utensils. Subsequently, residents were observed drinking from dishware that had not been properly sanitized. Food was served with utensils and/or plated atop dishware that had not been properly sanitized. An Immediate Jeopardy (IJ) at CFR 483.65, Infection Control; and cross referenced to CFR 483.70 (c) (2) "Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition" was identified on September 13, 2011 at 5:54 PM. The findings include: At 5:05 PM on September 13, 2011 an observation of the dish machine was conducted. In four (4) of five (5) dish wash cycles observed, the final rinse temperature gauge failed to reach 180 degrees F. The highest temperature observed was 138 degrees F. A face-to-face interview was conducted with Employee #13 at the time of the observation. He/she acknowledged that the final rinse temperature gauge did not reach 180 degrees F in four (4) of five (5) wash cycles observed. Employee #13 stated, " I observed this today (September 13, 2011) at 12:30 PM. I called (company) and they said I think it ' s my booster heater. I then called (the facilities equipment contractor) and they said they would be out here (at the facility) tomorrow. Dinner is being served now (5:00 PM). The residents are currently eating off china plates and utensils from today's dish machine wash cycle. " Employee #13 was then queried as to who made the decision to send the china and utensils that were not properly sanitized to the resident units for the dinner meal. He/she replied, I made the decision to send the china upstairs. " Additionally, residents were served and ate lunch off china/dishware and utensils that were washed by the dish machine that did not reach the 180 degrees F for sanitation. The dish machine temperature logs from April 2011 through September 13, 2011 were reviewed on September 13, 2011 at approximately 4:30 PM. A review of the logs revealed several dates when the dish machine temperatures were recorded to be less than 180 degrees Fahrenheit (F) (the point of sanitation - see chart below). Dishwasher Temperature Check Sheet Carroll Manor Food and Nutrition Services Department DateTimeWash TempFinal Rinse Temp9/13/11PMNot recorded0 at 12:009/2/11PM 09/9/11PM 66/2 /11AM 96/3/11AM 96/3/11PM 96/4/11PM 86/6/11AM 96/6/11PM 06/8/11AM 96/9/11PM 86/10/11PM160No data recorded6/11/11PMNo data recordedNo data recorded6/14/11AM 96/15/11PM 66/16/11PM 66/17/11PM 96/18/11AM 94/10/11AM 84/18/11AM 24/19/11AM 94/20/11AM 94/21/11AM 94/23/11AM 84/23/11PM 94/24/11AM 94/24/11PM 94/24/11 (as recorded)PM 94/25/11PM 94/26/11PM 94/27/11AM 84/28/11AM 94/29/11AM 94/30/11AM 94/30/11PMNo data recordedNo data recorded Additionally, after a review of the dish machine and refrigerator/freezer temperature logs, the surveyor asked for copies of all the logs that were reviewed on September 13, 2011 at approximately 4:45 PM. Multiple requests were made for the copies of the temperature logs from 4:40 PM on September 13 to September 14, 2011 at 12:05 PM. At that time Employee #15 provided the surveyor with multiple binders containing temperature logs dating from April 2011 through September 13, 2011. These temperature logs had different hand writing and information that was not the same as the temperature logs that were reviewed on September 13, 2011 at approximately 4:40 PM. The surveyor then requested a copy of what was originally reviewed. Approximately 45 minutes later Employee #15 returned to the surveyor with a copy of the logs that were originally reviewed and stated, (The surveyor was informed) " Employee #13 had them. Employee #13 made them up (the logs) because he/she could not find the original sheets. " Employee #15 apologized and stated that the information in the binders are the original logs. Further Observations: An observation of the dining service on the fourth floor on September 13, 2011 at 5:50 PM revealed residents were escorted to the dining room and seated at tables with place settings that included silverware enclosed inside of a plastic sleeve and glasses filled with water. One resident was observed drinking water from the glass provided. Food was plated with serving utensils. An observation of the dining service on the fifth floor on September 13, 2011 at 5:50 PM revealed residents were seated at tables with glasses filled with water at the table settings. Residents were observed drinking water from the glasses provided. An observation of the dining service on the first floor on September 13, 2011 at 5:57 PM revealed residents were seated at the dining tables with place settings that included a glass of water, a glass of juice, silverware and napkins. Several residents were observed drinking either water or juice from the glasses provided. Observations of the 2nd and 3rd floor on September 13, 2011 at 5:45 PM revealed dining services had not begun, however; desserts were pre-plated on dishware and stacked on shelves in a transport cart. In summary, residents were observed drinking from dishware that had not been properly sanitized. Food was served with utensils and/or plated atop dishware that had not been properly sanitized. Facility staff failed to implement paper products or other measures to prevent the potential spread of infection. A face-to-face meeting was conducted with Employees #1 and #2 on September 13, 2011 at 5:45 PM. An Immediate Jeopardy (IJ) was called at 5:54 PM on September 13, 2011 for facility's failure to sanitize china/dishware and utensils per standard precautions, the residents were observed drinking/eating with china/dishware that had not been properly sanitized. The allegation of removal of the Immediate Jeopardy situation was received and verified on September 14, 2011 at 3:00 PM and the Immediate Jeopardy was lifted at this time. B. Based on dining observations, it was determined that facility staff failed to ensure that residents hands were sanitized prior to eating and facility staff serving residents failed to sanitize or cleanse their hands between serving residents and touching inanimate surface areas and staff failed to provide a clean clothing protector for one (1) resident. Residents #97 and #231. The findings include: 1. On September 12, 2011 during a lunch dining observation, staff failed to follow proper hand hygiene practices as follows: Residents were escorted directly from the dayroom to the dining room for the lunch meal. Containers of hand sanitizer were observed atop tables in the dining room and available for resident use. There was no evidence that the residents were offered the opportunity to cleanse their hands prior to being served. Staff who passed trays and provided tray set-up failed to cleanse/sanitize their hands between serving meals and handling inanimate objects such as the positioning chairs and touching counter tops. Staff who assisted residents with meal consumption failed to cleanse/sanitize hands between residents. Resident #97 and Resident #231 were seated at the same table. Employee #22 assisted both residents with meal consumption; however, failed to cleanse/sanitize his/her hands between assisting each resident. 2. An observation of the lunch meal on September 12, 2011 at 12:35 PM revealed facility staff failed to maintain proper infection control practices during assistance with dining as follows: Employee #21 was observed picking up a clothing protector off of the floor and placing the protector directly on the resident prior to feeding. An interview with the employee after the observation confirmed that a new clothing protector should have been provided for the resident.

Based on observations, record and staff interviews, it was determined that the facility staff failed to maintain the dish machine in safe operating condition, as evidenced by failure to ensure that the dish machine maintained an acceptable final rinse temperature to sanitize china/dishware and utensils. Subsequently, residents were observed drinking from dishware that had not been properly sanitized. Food was served with utensils and/or plated atop dishware that had not been properly sanitized. An Immediate Jeopardy (IJ) at CFR 483.70 (c) (2) "Maintain all essential mechanical, electrical, and patient care equipment in safe operating condition" was identified on September 13, 2011 at 5:54 PM. The findings include: The dish machine temperature logs from April 2011 through September 13, 2011 were reviewed on September 13, 2011 at approximately 4:30 PM. A review of the logs revealed several dates when the dish machine temperatures were recorded to be less than 180 degrees Fahrenheit (F) (the point of sanitation - see chart below). Dishwasher Temperature Check Sheet Carroll Manor Food and Nutrition Services Department DateTimeWash TempFinal Rinse Temp9/13/11PmNot recorded0 at 12:009/2/11Pm 09/9/11Pm 66/2 /11Am 96/3/11Am 96/3/11Pm 96/4/11Pm 86/6/11Am 96/6/11Pm 06/8/11Am 96/9/11Pm 86/10/11Pm160No data recorded6/11/11PmNo data recordedNo data recorded6/14/11Am 96/15/11Pm 66/16/11Pm 66/17/11Pm 96/18/11Am 94/10/11Am 84/18/11Am 24/19/11Am 94/20/11Am 94/21/11Am 94/23/11Am 84/23/11Pm 94/24/11Am 94/24/11Pm 94/24/11 (as recorded)Pm 94/25/11Pm 94/26/11Pm 94/27/11Am 84/28/11Am 94/29/11Am 94/30/11Am 94/30/11PmNo data recordedNo data recorded At 5:05 PM on September 13, 2011 an observation of the dish machine was conducted. In four (4) of five (5) dish wash cycles observed, the final rinse temperature gauge failed to reach 180 degrees F. A face-to-face interview was conducted with Employee #13 at the time of the observation. He/she acknowledged that the final rinse temperature gauge did not reach 180 degrees in four (4) of five (5) wash cycles observed. Employee #13 stated, " I observed this today (September 13, 2011) at 12:30 PM. I called (company) and they said I think it ' s my booster heater. I then called (the facilities equipment contractor) and they said they would be out here (at the facility) tomorrow. Dinner is being served now (5:00 PM). The residents are currently eating off china plates and utensils from today's dish machine wash cycle. " Employee #13 was then queried as to who made the decision to send the china and utensils that were not properly sanitized to the resident units for the dinner meal. He/she replied, " I made the decision to send the china upstairs. " Futher Observations: An observation of the dining service on the fourth floor on September 13, 2011 at 5:50 PM revealed residents were escorted to the dining room and seated at tables with place settings that included silverware enclosed inside of a plastic sleeve and glasses filled with water. One resident was observed drinking water from the glass provided. Food was plated with serving utensils. An observation of the dining service on the fifth floor on September 13, 2011 at 5:50 PM revealed residents were seated at tables with glasses filled with water at the table settings. Residents were observed drinking water from the glasses provided. An observation of the dining service on the first floor on September 13, 2011 at 5:57 PM revealed residents were seated at the dining tables with place settings that included a glass of water, a glass of juice, silverware and napkins. Several residents were observed drinking either water or juice from the glasses provided. Observations of the 2nd and 3rd floor on September 13, 2011 at 5:45 PM revealed dining services had not begun, however; desserts were pre-plated on dishware and stacked on shelves in a transport cart. In summary, residents were observed drinking from dishware that had not been properly sanitized. Food was served with utensils and/or plated atop dishware that had not been properly sanitized. A face-to-face meeting was conducted with Employees #1 and #2 on September 13, 2011 at 5:45 PM. An Immediate Jeopardy (IJ) was called at 5:54 PM on September 13, 2011 for facility's failure to sanitize china/dishware and utensils per standard precautions, the residents were observed drinking/eating with china/dishware that had not been properly sanitized. The allegation of removal of the Immediate Jeopardy situation was received and verified on September 14, 2011 at 3:00 PM and the Immediate Jeopardy was lifted at this time.

Based on observation, staff interviews and record review for Resident #1, it was determined that the facility failed to ensure that Resident #1 ' s side rails were more than one (1) inch above the top of the mattress. Subsequently, the resident was rolled to the side, rolled over the side rail, fell on the floor and suffered a laceration to the left eye, fracture left hip and fractured C2 vertebrae. The findings include: Resident #1was born on February 10, 1925 and was admitted to the facility on [DATE]. According to a quarterly Minimum Data Set assessment completed December 9, 2011, the resident was assessed with [REDACTED]. Resident #1 was assessed as being totally dependent for all Activities of Daily Living in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated March 5, 2011 at 1500 (3:00 PM): " Resident was receiving care this A.M. from the CNA. During the bath, the resident was rolled to his/her side and accidentally fell out of bed and onto the floor. He/she sustained a laceration to his/her left eyebrow area that was bleeding profusely. Bandages, ice and pressure were applied to left eyebrow laceration. 911 was called. MD and family member were notified. The resident was verbal with stable vitals on transfer to the (hospital). " According to a nurse ' s note dated March 5, 2011 at 1330 (1:30 PM): (The nurses ' notes were out of time sequence in the resident ' s record) " Writer was called by CNA, observed resident bleeding profusely from left upper eyelid laceration in bed. CNA stated, " While I was providing care, I turned (Resident #1) and he/she rolled off the bed. " Supervisor notified and came to the unit. Ice pack placed to laceration for pressure. The resident ' s side half-rails were raised on the side of the bed where the resident rolled out. The resident rolled to the side assisted. The resident was positioned on the stretcher by EMT with a board to stabilize his/her on transfer. " According to a nurse ' s note dated March 5, 2011 at 1500 (3:00 PM): " Resident was receiving care this A.M. from the CNA. During the bath, the resident was rolled to his/her side and accidentally fell out of bed and onto the floor. He/she sustained a laceration to his/her left eyebrow area that was bleeding profusely. Bandages, ice and pressure were applied to left eyebrow laceration. 911 was called. MD and family member were notified. The resident was verbal with stable vitals on transfer to the (hospital). " March 5, 2011 at 1330 (1:30 PM): (The nurses ' notes were out of time sequence in the resident ' s record) " Writer was called by CNA, observed resident bleeding profusely from left upper eyelid laceration in bed. CNA stated, " While I was providing care, I turned Resident #1 and she rolled off the bed. " Supervisor notified and came to the unit. Ice pack placed to laceration for pressure. The resident ' s side half-rails were raised on the side of the bed where the resident rolled out. The resident rolled to the side assisted. The resident was positioned on the stretcher by EMT with a board to stabilize her on transfer. " March 5, 2011 at 13:30 (1:30 PM): " Writer was called by CNA observed resident bleeding profusely from left upper eyelid laceration in bed, CNA stated, " While I was providing care, I turned and he/she rolled off the bed. Supervisor notified and came to the unit. Ice pack placed to laceration for pressure V/S (Vital Signs) 74 (pulse), 22 (Respirations), 127/92 (Blood Pressure), 98.0 (oral temperature in degrees Fahrenheit), Blood Sugar 135. RP (responsible party) (physician) notified and order given to transfer resident via 911. Resident transferred to (hospital). " At the time of the onsite observation, the resident was in the hospital. The resident ' s bed and alternating air pressure mattress were inspected on March 9, 2011 at 8:00 AM in the presence of Employees #1 and #2. Employee #2 inflated the alternating pressure mattress. The upper half side rails were raised. The top of the mattress was one (1) inch below the top of the side rail. A bed without the alternating air pressure mattress was inspected at the same time. The upper side rails were raised. The top of the mattress was seven and one-half (7 ?) inches below the top of the side rail. A face-to-face interview was conducted with Employee #3 on March 9, 2011 at 9:30 AM. Employee #3 was asked if she had ever cared for Resident #1. Employee #3 stated, " Yes, I have taken care of him/her. (Resident #1) has jerky movements of his/her shoulders and arms. You have to be careful when you turn him/her because he/she jerks and moves. We put a pillow against the side rail that he/she is turned towards so he/she won ' t fall. We all do that. " A telephone interview was conducted with Employee #4 on March 11, 2010 at 9:15 AM. Employee #4 was the CNA who was giving care when Resident #1 rolled out of bed. Employee #3 stated, " I have been working with Resident #1 since September of last year (2010) ...I washed his/her back side first ... Then I turned him/her to his/her side and he/she started jerking and he/she just kept going over the rail. I couldn ' t catch him/her. I usually put a pillow against the side rail on the side that I turn him/her to because the mattress is so high. I didn ' t do it this time. The pillow was at the foot of the bed. It was just a silly mistake. I am so sorry that I didn ' t do that ....When he/she was on the floor I put on the call light and I didn ' t think they came fast enough. I just panicked. I picked Resident #1 up off the floor. Resident #1 was naked and bleeding and lying on the floor so I picked him/her up and put him/her in the bed. They teach us not to do that, but I panicked and picked him/her up. " A physician's order [REDACTED]. " This was ordered subsequent to the resident ' s sacral pressure sore. The following care plan problem was reviewed: " Involuntary movement of upper body with poor trunk control. " Approaches included: " 1. Monitor resident every two hours and PRN per facility protocol. 2. Educate resident staff and family. 3. Monitor side effects of antidepressant (Celexa). 4. Bed in lowest position. 5. Floor mat on both sides of bed and bed rails to facilitate turning. " Facility staff identified that Resident #1 had jerky movements of the upper body. Facility staff placed an alternating pressure mattress on the resident ' s bed, with only one (1) inch between the top of the mattress and the top of the side rail. The CNAs identified that a pillow needed to be placed against the side rail toward which the resident was turned to prevent the resident from falling out of the bed. The CNA caring for the resident when the resident fell out of bed acknowledged that he/she did not place the pillow against the side rail and subsequently the resident rolled over the side rail and fell out of bed sustaining a fractured left hip, fractured C2 vertebrae and left eye laceration. The record was reviewed March 9, 2011.