Every finding on record at Bridgepoint Subacute and Rehab Capitol Hill

Based on record review and staff interviews, for one (1) of 53 sampled residents, facility staff failed to order a wound consult and treatment for a resident who was observed with blisters on his right buttock. Subsequently, five (5) days later, the resident was observed with a Stage 3 pressure ulcer to his right buttock. Resident #38.The findings included: A review of the facility policy entitled Pressure Ulcer/Injury Assessment, reviewed 12/2025 that documented: Steps in the Procedure:Gather assessment tools and documentation and conduct the assessment in the manner most appropriate to the resident's condition and willingness to participate. If necessary, allow the resident to take rest periods during the assessment. Conduct a structured pressure ulcer/injury risk assessment using a facility-approved tool. Conduct a comprehensive skin assessment with every risk assessment. a.When conducting a skin assessment, provide for the resident's privacy. b.Once inspection of skin is completed document the findings on a facility-approved skin assessment tool. c. If a new skin alteration is noted, initiate a (pressure or non-pressure) form related to the type of alteration in skin. Resident #38 was admitted to the facility on [DATE] with diagnoses that included: Pressure Ulcer of Sacral Region, Stage 4; Type 2 Diabetes Mellitus without Complications, Metabolic Encephalopathy; Muscle Weakness (Generalized); and Encounter for Attention to Gastrostomy. Review of Resident #38's medical record revealed: Physician's orders dated 05/30/25 that directed, Inspect the skin of all admissions and if the resident develops a wound during stay, evaluate and treat as indicated; Turn and reposition every 2 hours. A physician's order dated 06/25/25 that directed: Shower/Complete bed bath, every Wednesday and Saturday. A quarterly minimum data set assessment dated [DATE] that documented, Resident #38 was at risk for developing pressure ulcers and had one Stage unhealed Stage 4 pressure ulcer that was present upon admission. A skin and wound note signed by [Employee # 27/Nurse Practitioner for Wound Care Team] dated 02/03/26 that documented: . Assessment/Plan: Focused wound examination completed today. Stage 4 pressure injury to the sacrum is improving in size. Increase in undermining noted as above. The tissue to the wound bed is healthy, beefy red. Bone exposure persists, though wound is stable. No, immediate concerns for infection at this time. -Continue with the treatment recommendations above. Of note, on 02/04/26 there was no documented evidence that any other wound except the sacral wound was assessed or treated by the wound care team. A care plan initiated on 04/15/25 that documented: Focus: [Resident #38] has actual pressure ulcer development r/t immobility and fragile skin. Goal [Name of Resident #38] will have no complications r/t (related to) pressure ulcer of the sacrum through the review date. Interventions: Administer medications as ordered; Monitor/document for side effects and effectiveness; Administer treatments as ordered and monitor for effectiveness; Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. The resident needs to turn/reposition at least every 2 hours, more often as needed or requested; The resident requires low air loss mattress; Treat pain as per orders prior to treatment/turning etc. to ensure The resident's comfort; Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. An e-Interact change in condition progress note dated 02/04/26 that documented in part:Situation: Change in condition/s(CIC) reported are/were skin wound or ulcer.During the assessment noticed open blister on the Rt. (right) side of the gluteal area. Cleanse(d) the wound with cleanser and apply xeroform dressing. Obtained wound consult; responsible party notified. No pain or distress noted. Primary Care Provider responded with the following feedback: Cleanse the wound with cleanser and apply xeroform dressing. Obtained wound consult. Review of the physician's orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR) for February 2026 showed no documented evidence that the Xeroform or wound consult were ordered as indicated on e-Interact progress note. Review of the progress notes from 02/04/26 to 02/09/26 showed no documented evidence that facility staff followed the procedure steps of using an assessment tool for assessing pressure ulcers/ injuries as documented in their policy. A wound assessment report dated 02/09/26 documented: Wound Evaluation Date: 02/09/2026.Location: Right buttock.Measurements: Length: 2.30 cm (centimeters) Width: 1.00 cm; L (length) x W (width): 2.30 cm2 (centimeters squared); Depth: 0.30 cm.Etiology: Pressure Ulcer/Injury, Stage/Severity: Stage 3. Acquired in House: Yes.Date Wound Acquired: 02/09/2026. A physician's order dated 02/09/26 directed: Right buttock wound; Cleanse with wound cleanser, apply silver alginate, cover with bordered dressing daily and prn every day shift.During an observation of wound care rounds on 05/21/26 at 10:26 AM with Employee #27 (Consultant Wound Care Nurse Practitioner), it was noted that Resident #38 had three wounds: a Stage 4 sacral wound, a Stage 4 right buttock wound, and a Stage 2 left heel wound. During a face-to-face interview on 04/21/2026 10:29 AM with Employee #27, he stated that currently, Resident #38 was being seen weekly by the wound care team for three (3) pressure ulcers/injuries: a Stage 4 sacral wound (present on admission), a facility-acquired Stage 4 wound to the right buttock (started off as a Stage 3), and a facility-acquired Stage 2 pressure injury (opened blister) to the left heel. When asked if facility staff had made him aware of a blister on Resident #38's right buttock prior to 02/09/26, he stated, No. I first observed the Stage 3 pressure ulcer to the right buttock during wound care rounds for the resident on 02/09/26. A few weeks later, after closely reviewing my pictures of the wound from 02/09/26, I saw that there was slightly exposed bone visible, and I re-staged the wound as a Stage 4 pressure ulcer. When asked if a blister could progress to a Stage 3 pressure ulcer within 5 days, he stated , It is possible. A blister is a Stage 2 pressure injury that can be the first sign of more serious deep tissue injury underneath the skin. With residents who have fragile skin, such as Resident #38, lying in the same position, moisture, lack of proper treatment to the blister, and shearing of skin, could cause a blister to advance to a Stage 3 or Stage 4 pressure ulcer in a short period of time. During a face-to-face interview on 04/29/26 at 12:53PM, Employee #21 (Registered Nurse) stated that she noticed an open blister on Resident #30's right buttock during incontinent care (on 02/04/26). She further stated that she contacted the resident's representative and the physician immediately. Employee #21further stated that the physician told her to clean the wound, apply Xeroform dressing, and enter a wound consult in the resident's medical record. She commented further that she entered the treatment and wound consult orders and documented in an e-Interact progress note in the resident's medical record. When asked, Employee #21 was not able find the wound consult or the treatment orders that she stated she had entered on 02/04/26 in Resident #38's medical record. When asked if she used the assessment tool for pressure ulcers/injuries per facility policy, Employee #21 reported that she was not familiar with an assessment tool. During a face-to-face interview on 05/05/26 at 12:12 PM, Employee #28 (Wound Care Nurse) stated that all residents with wounds receive daily wound care (cleaning the wounds and changing wound dressings) daily by the wound care nurses. If the wound gets soiled or the dressing falls off, they are changed as needed by the nurses. Employee #28 added that when new skin areas are observed by staff, the nurse can either call the physician or notify the wound care nurses. Regarding Resident #38, Employee #28 stated that the resident was seen by the wound care nurse daily and that she entered the orders for a wound consult and for wound treatment orders on 02/09/26 for the Resident's right buttock after observing the wound with the wound care treatment team. She further commented that she was never made aware that Resident #38 was observed with a blister to his right buttock by the nurse on 02/04/26. Employee #28 also stated that she had not noticed any skin alterations to the resident's right buttock prior to 02/09/26, when it was documented at a Stage 3. Of note, there was no documented evidence that facility staff followed the procedure steps for assessing pressure ulcers/ injuries as documented in their policy. When asked if she used the assessment tool when assessing resident's wounds, , Employee #28 stated that she was not familiar with the assessment tool per the facility's policy. During a face-to-face interview on 05/05/26 at 3:59 PM, Employee #2 (Director of Nursing), stated that she was not familiar with the assessment tool referred to in the facility's policy. The nurse assigned to the resident and the wound care nurses assess the wounds and document their findings in the progress notes. The evidence showed that Employee #21 first observed a blister on Resident #38's right buttock on 02/04/26 and notified the resident's primary care physician. However, there is no documented evidence that the facility staff followed their pressure ulcer injury policy. ,wound consult or the treatment for Xeroform to be applied to the area were ever ordered as specified by the physician. However, there is no documented evidence that the facility staff followed their pressure ulcer injury policy. Subsequently, 5 days later, on 02/09/26, the right buttock blister was assessed to be a Stage 3 pressure ulcer.

Based on record review and staff interviews, for one (1) of 53 sampled residents, facility staff failed to complete a thorough investigation for a facility-reported incident (FRI) that alleged a facility staff removed a 10-tablet blister pack of Resident #38's narcotic pain medication.The findings included:Resident #38 was admitted to the facility on [DATE] with diagnoses that included: Pressure Ulcer of Sacral Region Stage 4, Anoxic Brain Damage; Epilepsy; and Muscle Weakness.Review of the resident's medical record revealed the following:A physician's order dated 08/21/25 that directed: Tramadol (narcotic pain reliever) HCl oral tablet 50 mg (milligram), give 50 mg via PEG-Tube (Percutaneous Endoscopic Gastrostomy tube) every 8 hours for moderate to severe pain.The Medication Administration Records (MAR) for August 2025 and September 2025 showed that facility staff documented that they administered Tramadol HCl oral tablet 50 mg via PEG-Tube (every 8 hours for moderate to severe pain at 2:00 AM, 10:00 AM, and 6:00 PM from 08/21/25 to 09/09/25.A FRI submitted online to the State agency on 09/01/25 documented in part:On 09/01/25, at around 8:05 AM, it was reported that Tramadol HCL Oral Tablet 50 mg (milligram) bubble pack belonging to [Resident #38] was missing. [Nurse Practitioner/NP] made aware. This is the initial report, investigation ongoing. A final report received on 09/18/25 at 4:45 PM that documented in part:This is the final report to the self-report that was submitted on 09-01-2025 regarding the missing Tramadol HCL Oral Tablet 50 mg (10 tablets) bubble pack belonging to [Resident #38]. The nurse involved was interviewed (Employee #30) and a statement was obtained. [Employee #30] was unable to explain and account for the missing narcotics.During the investigation, staff were interviewed, and statements were obtained. Investigation shows that [Employee #30] was still in possession of the narcotics as evidenced by her signatures on the MAR and narcotic sheet.At the completion of a thorough investigation, the facility was able to substantiate that 10 tablets of Tramadol 50 mg bubble pack were missing and cannot be accounted for based on the narcotic count sheet reconciliation. Employee #30 has been separated from the facility to meet facility expectations regarding proper handling of controlled substances.Review of the facility's investigation documents on 05/04/26 showed that thorough investigation of the incident was not conducted as evidenced by:No documented evidence that Employee #30 did not work at the facility during the investigation period for the incident;No documented evidence to show that facility staff investigated why the times and dosages of the resident's Tramadol on the Controlled Drug Receipt/Record Disposition Form were inconsistent with the physician's order. During a face-to-face interview on 05/06/26 at approximately 3:00 PM, Employee #2 (Director of Nursing/DON) acknowledged the findings and made no further comments.

Based on record review and staff interview, for one (1) of 53 sampled residents, facility staff failed to revise and update Resident #112's care plan with goals and interventions to address a left medial lower leg and right knee abrasions. The findings included: Review of the facility's Pressure Ulcer/Injury Risk Assessment policy dated 05/24/24 documented in part: Develop the resident-centered care plan and interventions based on the risk factors identified in the assessments, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. The interventions must be based on current, recognized standards of care. The effects of the interventions must be evaluated. The care plan must be modified as the resident's condition changes, or if current interventions are deemed inadequate. Resident #112 was admitted to the facility on [DATE] with multiple diagnoses that included Pressure Ulcer of Sacral Region, Encephalopathy, Chronic Respiratory Failure with Hypoxia and Iron Deficiency Anemia. Review of the resident's medical record revealed the following:09/18/24 at 8:03 PM admission Summary: [AGE] year-old female admitted to unit at 6.56 PM. 09/18/24 admission Braden Scale for Predicting Pressure Ulcer Sore Risk: Score, 11.0, High risk. 09/19/24 at 10:03 AM admission Skin and Wound Note:Wound: 1 - midline abdomenPrimary Etiology: SurgicalStage/Severity: Partial ThicknessWound Status: Present on AdmissionSize: 1 (centimeters (cm) x 1 cm x 0.1 cm. Calculated area is 1 square (sq) cm.Wound: 2 - sacrumPrimary Etiology: PressureStage/Severity: Stage 3Wound Status: Present on AdmissionSize: 2 cm x 3.5 cm x 0.1 cm. Calculated area is 7 sq cm. A care plan focus area [Resident #112] has pressure ulcer of the sacral area related to (r/t) disease process and immobility with goals and interventions was initiated on 09/21/24. A care plan focus area , [Resident #112] has actual impairment to skin integrity of the mid abdomen r/t surgical wound with goals and interventions was initiated on 09/21/24. An admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded the following: Brief Interview for Mental Status not conducted because resident rarely/never understood; and had one stage 3 pressure ulcer/injury over bony prominence.10/01/24 at 8:53 AM Skin and Wound Note:New right knee and left medial lower leg abrasions. 10/08/24 at 9:19 AM Skin and Wound Note:Right knee and left medial lower leg abrasions slowly improving in epithelium. Midline abdominal surgical wound slowly improving in stable epithelium. Sacral PI wound continues to evolve, with improvement in slough bone now exposed. A Complaint, #2592261, received by the State Agency on 08/15/25 documented in part:The purpose for this correspondence is to request the Department of Health to investigate to determine if [facility name] has adequate and appropriate policies, procedures and or protocol in place to mitigate the development of skin breakdown and pressure ulcers. The evidence showed that facility staff failed to update Resident #112's care plan after she developed right knee and left medial lower leg abrasions on 10/01/24. During a face-to-face interview on 04/22/26 at 1:10 PM, Employee #2 (Director of Nursing/DON) reviewed Resident #112's care plan, acknowledged the findings and stated, Updating the care plan is up to the unit managers, supervisors and the interdisciplinary team.

Number of residents sampled: Number of residents cited: Based on observation, record review, and staff and family interview, for one (1) of 53 sampled residents, the facility failed to ensure that: (1) Resident 43's gown and linen were dry and free from stains, and incontinent care was provided in a timely manner. And (2) Resident #43 was turned and repositioned in a timely manner. (Resident #43)The findings included: Resident#43 was admitted to the facility on [DATE]. The resident has a history of Cerebral Infarction, Muscle Weakness, and Stage 3 and Stage 4 Pressure Ulcers.A review of a quarterly Minimum Data Set assessment dated [DATE] documented that the resident did not have a Brief Interview for Mental Status summary score, indicating the assessment was not conducted. The resident was coded for being dependent on staff for activities of daily living, always incontinent of bowel, having a urinary catheter, and having one Stage 3 and one Stage 4 pressure wound. 1. An observation on 04/29/26 at 10:20 AM showed the resident lying in bed with light red wet spots on his gown and bed linen. The resident was also noted to have dry, brown colored stool on his left thigh. The complainant (daughter) was at the bedside during the observation.During a face-to-face interview on 04/29/26 at approximately 10:25 AM, the complainant stated that she often finds her father needing care. During a face-to-face interview on 04/29/26 at 10:30 AM, Employee #21 (assigned RN) stated that the resident's gown and linen may be wet and stained by medication. The employee said she may have accidentally spilled medication while administering it. During a face-to-face interview on 04/29/26 at 10:35 AM, Employee #22 (assigned CNA) stated that he made rounds on the resident when he first arrived at 7 AM. The employee said at that time the resident's bed was clean and he did not need incontinent care. Additionally, the employee then said, I'm here now to provide care. 2. A care plan dated 03/30/26 documented in part, Focus - [Resident #43 has pressure ulcers related to disease process (Chronic respiratory failure, chronic kidney disease, diabetes.immobility.Intervention- The resident needs assistance to turn/reposition at least every 2 hours or more often as needed or requested.A complaint intake (# 2739155) submitted to the State Agency on 04/08/26 documented in part, I am writing to you with urgent concerns regarding my father,[Resident #43], especially following his recent diagnoses of sepsis, pneumonia, and dehydration at [Hospital's name].In light of these developments, we are requesting several critical adjustments to his care.The implementation of a strict and visible 2-hour repositioning schedule, which is vital due to his prolonged immobility.During a telephone interview at approximately 1 PM on 04/27/26, the complainant stated that the staff does not turn and reposition her dad for hours. The complainant also said that she often turns her dad if the staff does not turn him within 3 hours. She said that the last time she had to turn him was last week. Additionally, the complainant stated that she has talked with the Administration many times about her concern, but nothing has changed. Multiple observations at approximately 4:50 AM, 8:50 AM, 9:55 AM, and 10:20 AM on 04/29/26 showed Resident #43 lying supine. The resident was awake, non-verbal, and the tracheostomy site was clean.During a face-to-face interview on 04/29/26 at approximately 5:00 AM, Employee #24 (assigned night-shift CNA) stated that he had just completed care for the resident, which included a bed bath. During a face-to-face interview at approximately 1 PM on 04/29/26, Employee #22 (assigned dayshift CNA) stated that he conducted his first observation of the resident at around 7 AM, when he arrived; he did not reposition the resident. He did, however, reposition the resident after he provided care for activities of daily living, which began around 10:30 AM.

Number of residents sampled: Number of residents cited: Based on record review, staff interview, and family interview, the facility's staff failed to ensure that a resident with a tracheostomy was accompanied by nursing staff during a podiatry appointment for one of the 53 sampled residents. (Resident #43) Resident #43 was admitted to the facility on [DATE] with multiple diagnoses, including Aphasia, Chronic Respiratory Failure, Tracheostomy, and Muscle Weakness.A physician order with a re-order date of 01/31/26 instructed, On Trach collar: FI02:28%, Trach Type: [NAME], Trach Size: XL 7 every shift. Trach and suction care by a respiratory therapist and a nurse every shift.A quarterly Minimum Data Set assessment dated [DATE] showed that the resident did not have a Brief Interview for Mental Status summary score, indicating that the assessment was not conducted. Additionally, the resident was coded for requiring maximum staff assistance with all activities of daily living, tracheostomy care, and suctioning. The resident was also coded for receiving respiratory services. A nursing note dated 02/05/26 at 5:48 pm documented in part, Resident went for the podiatry appointment, and back at 3:30 [PM] by [Name of company] transportation. Resident Alert [at] this time, vital signs within normal limits. A compliant intake (#2739155) submitted to the State Agency dated 02/09/26 documented in part, I am writing to you with profound concern regarding my father,[Resident #43's name], transportation to his podiatry appointment on Thursday, February 5th. It was deeply distressing to learn that he, an incapacitated patient with a tracheostomy, was reportedly transported without any accompanying supervision or support from Bridgepoint staff. This lapse was brought to my attention by the nurse manager at [Name of Podiatry Department], who contacted me after the appointment. She expressed significant alarm over the lack of awareness regarding my father's tracheostomy. The [Name of office] staff were unprepared to handle a potential airway emergency, such as the need for suction, due to the absence of appropriate equipment and prior notification. This oversight placed my father, who is unable to advocate for himself, in a precarious and potentially life-threatening situation.Multiple observations from 04/20/26 to 04/29/26 showed the resident lying in bed with head of bed at a 90-degree angle. The resident was noted to have a tracheostomy tube. The secretions from the tracheostomy were thin and clear, no smell noted, no redness noted at the stoma site, Fraction of Inspired oxygen at 28% via tracheostomy collar, tracheostomy ties were clean and secure, and the split gauze under the tracheostomy tube was clean. During a face-to-face interview on 04/29/26 at approximately 9:00 AM, Employee #23(RN/Unit Manager) stated that the resident was sent to the podiatry appointment without a nurse or tracheotomy supplies. The employee said it was an oversight because they thought the transportation company that took the resident to the appointment would have provided supervision during the appointment. Additionally, the employee stated that the facility now ensures that a nurse accompanies any residents with respiratory needs on appointments. During a face-to-face interview on 04/29/26 at approximately 10 AM, the complainant stated that she was called by a nurse from the Podiatry office. The nurse left her a voice message that said the resident was sent to the office without an employee from the facility or tracheostomy supplies. The nurse also said that if the resident required suctioning, the office would not have been able to provide that type of care. Additionally, the complainant stated that Employee #23 approached her and apologized, saying it was an oversight to send the resident out without a nurse. During a telephone interview on 04/29/26 at approximately 1 PM, a customer service representative from the transportation company stated that the paramedic may stay with a patient (1st) during an appointment. However, if they are scheduled to transport another patient (2nd), then they will drop the first patient off at their appointment.

Number of residents sampled: Number of residents cited: Based on record review, staff interview, and family interview, the facility failed to ensure Employee #22 (CNA) did not remove a soiled sacral dressing and replace it with a clean gauze for one of 53 sampled residents. (Resident #43)Resident#43 was admitted to the facility on [DATE]. The resident has a history of Cerebral Infarction, Muscle Weakness, and Stage 3 and Stage 4 Pressure Ulcers.A care plan with a review date of 12/18/25, documented in part, Focus [Resident #43 has pressure ulcers related to disease process (Chronic respiratory failure, chronic kidney disease, diabetes.immobility.Intervention- administer treatments as ordered and monitor for effectiveness [LPN, RN, or NP]. A wound assessment report dated 02/24/26 documented in part, Location-sacrum, measurements length 4.00 cm (centimeters), width-6.00 cm, depth 2.90 cm. Observation- Stage 4.A physician order with a reorder date of 03/03/26 instructed, Sacrum wound: Cleanse with wound cleanser, apply collagen to wound bed, hydrogel moistened rolled gauze [packing dressing] to undermining from 7 o'clock to 5 o'clock, cover with bordered dressing daily and as needed.A complaint intake (#2739155) submitted to the State Agency on 03/09/26 document in part, I also need to report a new and very concerning incident that occurred on Friday, 03/06/26, afternoon involving my father [Resident #43]. During a personal care session, a Certified Nursing Assistant [Employee #22] was assisting him with hygiene and wound dressing changes. I observed the CNA using the same pair of gloves to clean fecal matter and then immediately remove my father's old wound dressing. This practice raised immediate concerns about cross-contamination and adherence to proper infection control protocols. Furthermore, a specific dressing, which I refer to as a rolling glaze, appeared to be significantly stuck to my father's skin and underlying tissue. The CNA attempted to remove it by forcefully pulling it. I made eye contact, and the CNA then sprayed wound-cleaning solution directly onto the stuck dressing. Without allowing any time for the solution to penetrate or loosen the adhesive, the CNA immediately pulled the dressing again, causing my father's skin to bleed noticeably.During a face-to-face interview at 7:30 AM on 04/29/26, Employee #21(CNA) stated that he does not provide wound care. He said that he assists the nurse with positioning during wound care. And he will also notify the nurse if a resident's wound is soiled or if it comes off during bathing. During a face-to-face interview at approximately 9 AM on 04/29/26, Employee #23 (RN/Unit Manager) stated that no family notified her that a CNA was providing wound care. Additionally, the employee stated that it is not in the CNA's scope of practice to provide wound care. During a face-to-face interview starting at approximately 10 AM, the complainant stated that Employee #22 (CNA) has changed the resident's sacral wound dressing on several occasions. The complainant said that during one dressing change, the employee did not change his gloves after removing the sacral dressing, which was soiled with stool. Instead, he started providing wound care. He attempted to pull out the rolling gauze [packing dressing inside the sacral wound] without moistening it, but it was stuck, so he used a spray to loosen it. The wound did bleed. He covered the wound with gauze and taped it. He did not sign or date the dressing. During the interview, the complainant demonstrated how the employee provided wound care. Also, Employee #2 (DON) and Employee #23 (RN/Unit Manager) were present during the interview and demonstration. During a face-to-face interview at approximately 9 AM on 04/30/26, Employee #2 stated that she spoke with Employee #22, who stated that one time while he was providing incontinent care, he noticed that the resident's sacral dressing was soiled with feces. He removed the soiled dressing, cleaned the area, replaced it with a clean gauze, and secured it with tape. The employee stated that the resident was suspended until an investigation because the resident was working outside of his scope of practice.

Based on observation, record review, and staff interview, for one (1) of 53 sampled residents, facility staff failed to ensure proper storage of Resident #43's medication. The findings included:According to the manufacturer, Novo Nordisk, medical guidelines for Ozempic stated, Recommended Storage Conditions for Ozempic Single-patient-use pens (with multiple weekly doses): After first use of the Ozempic pen, the pen can be stored for 56 days at controlled room temperature 15 C to 30 C (59 F to 86 F) or in a refrigerator 2 C to 8 C (36 F to 46 F ).https://www.ozempic.comResident #43 was admitted to the facility on [DATE] with diagnoses that included: Morbid (Severe) Obesity and Chronic Obstructive Pulmonary Disease (COPD).Review of Resident #43's medical record revealed:A physician's order dated 10/29/25 that directed: Ozempic 2 mg/(milligram)/ dose. Subcutaneous Solution Pen-injector 8 mg/3ml (milliliters) (Semaglutide). Inject 2 mg subcutaneously in the morning every Wed (Wednesday) for 90 days. Give weekly.During observation of the medication storage refrigerator on 04/22/26 at 10:20 AM, it was noted that Resident #43 had an open box of Ozempic (Semaglutide, a weight-loss medication) multi-use pens. Handwritten on the box was Opened 11/02/25. The evidence showed that Resident #43's Ozempic medication pen was stored for use beyond the manufacturers recommended 56 days. The medication should have been discarded on 02/11/26.During a face-to-face interview with Employee #33 on 04/22/26 at 10:20 AM, acknowledged the findings and stated that she was unsure how long a pen of Ozempic can be used after being opened.

2. A policy titled, Smoking Policy with a review date of 12/2024 instructed in part, To protect the health, safety, and comfort of our residents, visitors, medical staff and employees . Bridge Point is a smoke free facility. Smoking may not occur with the facility. This policy is applicable to all employees, staff, visitors, and residents, both smokers and non-smokers. The information in this policy will be reviewed with all staff during orientation and on an annual basis .Residents receive information regarding policy during the admission process .Residents and visitor compliance with the policy is a shared responsibility of all Bridge Point employees and staff .The nursing facility acts to minimize the smoke (sp) to the greatest extent possible. The nursing facility will provide smoking jackets for resident use for safety . 2a. Resident #80 was admitted on [DATE] with multiple diagnoses including Chronic Respiratory Failure, Muscle Weakness, and Difficulty Walking. A quarterly Minimum Data Set assessment dated [DATE] documented in part, Brief Interview for Mental Status summary score of 15 indicating that the resident had an intact cognitive status. The resident was coded for having impaired bilateral lower extremities and requiring partial to maximum assistance from staff with activities of daily living. A review of a list of residents in the facility who smoke on 04/15/25 at approximately 3:45 PM, revealed Resident #10 and Resident #92 were identified by staff as smokers. At the time of review, Employee #1 (Administrator) and Employee #2 (DON) stated that they were a Non-Smoking Facility. Staff do not provide residents with assistance with smoking. The facility does not have a designated area for smoking. And all residents who smoke go outside and up the street away from the building when they smoke. On 04/15/25 starting at approximately 3PM, the State Survey Team conducted a tour of the facility that included observations, resident interviews, and staff interviews. The tour revealed that the facility had two additional residents who smoke (Residents #46 and #80). An observation on 04/15/25 at 3:45 PM revealed a designed smoking area sign posted on the wall to the left of the facility's main entrance door. At the time of the observation, Employee #1 (Administrator) stated the sign was an old sign, and that the area was not a designated smoking area. During an observation on 04/15/25 at approximately 4:45 PM, Resident #80 was lying in bed, alert and orientated to name, time, place, and situation. At the time of the observation, the resident stated that he started smoking again a few weeks ago. He said that he smokes daily outside of the building near the wheelchair ramp that's close to the entry door. Additionally, the resident said, I would never smoke in the building. It is a hospital, and everyone knows you don't smoke in a hospital. When asked if he had access to cigarettes and matches, the resident showed the surveyors an opened pack of cigarettes and a green butane lighter. Also, the resident said he was not provided with information about the facility's smoking policy. A review of Resident #80's medical record on 04/15/25 at approximately lacked documented evidence of a care plan addressing the resident smoking. During a face-to-face interview on 04/15/25 at approximately 5:30 PM, Employee #10 (RN/Nursing Supervisor) stated that Resident #80 was identified by staff as a smoker. The facility's protocol is that all residents who smoke have a care plan in place to address the resident smoking. The employee then said she reviewed Resident #80's medical record and did not see a smoking care plan. Additionally, the employee said that a smoking assessment would not be done unless the resident triggers for new behavior of smoking. During a face-to-face interview on 04/17/25 at approximately 9 AM, Employee #11 (assigned CNA) stated that she was not aware that Resident #80 was a smoker. Additionally, the employee said she did not know if residents were allowed to keep cigarettes and lighters in their person or in their rooms. And that she was not aware of the facility's smoking policy. During a face-to-face interview on 04/17/25 at approximately 9:15 AM, Employee #12 (assigned LPN) stated that Resident #80 is a smoker. The resident lets staff know when he is going out to smoke. Staff do not assist him with smoking. And she was not aware of the facility's policy with residents keeping their cigarettes, matches, or lighter on their person or in their room. She believed that Resident #80 is allowed to keep his cigarettes and lighter with him. 2b. Resident #46 was admitted on [DATE] with multiple diagnoses to include Chronic Obstructive Pulmonary Disease, History of Falls, Generalized Muscle Weakness, Schizophrenia, Bipolar and Anxiety. A Smoke-Safety Screen dated 12/04/23 documented in part, Resident had cognitive loss, visual deficits and dexterity problems. The resident smokes 2-2.5 cigarettes daily .has received cigarettes from other residents, possible new behavior .safe to smoke with supervision .unsafe for resident to smoke related to impaired decision making and limited mobility . Please note review of the resident medical record to include assessments and progress notes from 01/01/25 to 04/14/25 lacked documented evidence that the facility's staff monitored the resident for receiving cigarettes from other residents. A review of an annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status summary score of 12 indicating that the resident had a moderately intact cognitive status. Additionally, the resident was not coded for using tobacco products. A care plan with a revision date of 01/16/25 documented in part, Focus- [Resident #46] has a history of smoking related to lifestyle .Interventions - [Resident #46] was educated about the facility policy on smoking. The facility non-smoking facility and she verbalized understanding. Notify charge nurse immediately if it suspected that resident has violated facility smoking policy. Smoking cessation was offered. A quarterly MDS assessment dated [DATE] documented in part that the resident had a Brief Interview for Mental Status summary score of 11 indicating the resident had a moderately impaired cognitive status. Also, the resident was coded for requiring supervision to maximum assistance from staff with activities of daily living and independently using a manual wheelchair for mobility. During a face-to-face interview on 04/15/25 at approximately 4:50 PM, Resident #46 stated that she smokes outside the building near the wheelchair ramp. She also keeps her cigarettes or black and mild (cigar) on her person. She will ask residents who are outside smoking with her for a lighter or match. The resident stated that, I'm grown. I don't need no one to supervise me while I'm smoking. The resident also stated that when she goes outside, she does not announce that she is going out to smoke. During a face-to-face interview on 04/15/25 at approximately 5:30 PM, Employee #10 (RN/Nursing Supervisor) stated that Resident #46 was identified by staff as a smoker. Additionally, the employee stated that she had reviewed the resident record it did not see that the resident was being monitored for the behavior of asking other residents for cigarettes, as indicated on the smoking evaluation dated 12/04/23. During a face-to-face interview on 04/17/25 at approximately 9:30 AM, Employee #11 (assigned CNA) stated that Resident #46 was a smoker. She informs the nurses when the resident wants to smoke. She pushes the resident in her wheelchair outside (in front of the building) to smoke. Additionally, the employee said that she does not assist the resident with lighting light her cigarettes. And she does not know where the resident keeps her cigarettes, lighters or matches. Additionally, the employee said that she was not aware of the facility's smoking policy. During a face-to-face interview on 04/17/25 at approximately 9:40 AM, Employee #12 (assigned LPN) stated that Resident #46 is a smoker. The CNA accompanies her while she smokes. Also, the CNA is responsible for lighting the resident's #46's cigarette because the resident was not safe to do that task. 2c. Resident #92 was admitted on [DATE] with multiple diagnoses including Paraplegia, Muscle Weakness, Depression, Bipolar, and Anxiety. A review of the resident's medical record lacked documented evidence of a smoking care plan. A quarterly Minimum Data Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 15 indicating the resident had an intact cognitive status. The resident was also coded for impairment of upper extremities (both sides), impairment of lower extremities (both sides), requiring partial to maximum staff assistance with activities of daily living, and independently using a motorize wheelchair for mobility. During a face-to-face interview on 04/15/25 at approximately 5:30 PM, Employee #10 (RN/Nursing Supervisor) stated that Resident #80 was identified by staff as a smoker. The facility's protocol is that all residents who smoke should have a smoking care plan in their medical record. The employee then said she reviewed Resident #92's medical record and did not see a smoking care plan. Additionally, the employee said that the resident would not have a smoking assessment unless they trigger for a new behavior of smoking. During a face-to-face interview on 04/17/25 at approximately 10 AM, Resident #92 stated that he was a smoker and goes outside and to the street to the corner to smoke. The resident was asked if he had any smoking paraphernalia such as cigarettes and a lighter on his person and the resident stated, No, I don't have nothing [anything] on me, and my lighter is broke. When asked how he would light his cigarettes if he didn't have a lighter, the resident stated, I would just get a light from somebody else that's outside smoking. During a face-to-face interview on 04/17/25 at 10:20 AM, Employee #33 (CNA) stated that she was not aware of any residents that smoke. The employee also said that she was not aware where residents store their smoking paraphernalia. 2d. Resident #10 was admitted on [DATE] with multiple diagnoses including Nicotine Dependence, Paraplegia, Epilepsy, Lack of Coordination, Muscle Weakness, and Bipolar. A review of a care dated 01/04/24 documented in part, Focus - [Resident #10] is a cigarette smoker and does not wish to stop during the hospital stay .Interventions: Explore smoking apron, Educated about the facility policy on smoking. The Facility Non-smoking Facility and he verbalized understanding, Offer a nicotine patch. Offer smoking cessation classes. Resident able to smoke unsupervised per the smoking assessment. Resident smokes off [the] Facility premises. An annual Minimum Data Set (MDS) assessment dated [DATE] documented that the Brief Interview for Mental Status (BIMS) summary score of 15 Brief Interview for Mental Status (BIMS) summary score of 15 indicating that the resident had an intact cognitive status. Additionally, the resident was coded for having an impairment of the upper extremity (one-side), impairment of lower extremities (both sides), requiring set-up to partial staff assistance from staff with activities of daily living, independent with using his motorized wheelchair, and using tobacco products . A quarterly Smoking Safety Screen assessment dated [DATE] documented that the resident had a score of 1.0 indicating that the resident was safe to smoke without supervision. The assessment also documented in part, Smokes 5- 10 cigarettes per day, Can light his own cigarettes, Does not need the facility to store lighters and cigarettes, Adaptative equipment needed - cigarette holder, Safe to smoke independently . A quarterly Smoking Safety Screen assessment dated [DATE] documented that the resident had a score of 1.0 indicating that the resident was safe to smoke without supervision. The assessment also documented in part, Smokes 5- 10 cigarettes per day, Can light his own cigarettes, Does not need the facility to store lighters and cigarettes, Adaptative equipment needed - smoking apron and cigarette holder, Safe to smoke without supervision. A quarterly MDS assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of 15 indicating that the resident had an intact cognitive status. Additionally, the resident was coded for having an impairment of the upper extremity (one-side), bilateral impairment of lower extremities, requiring set-up to partial staff assistance with activities of daily living, and independent with using motorized wheelchair. During a face-to-face interview on 04/17/25 at 9:50 AM, Resident #10 stated, I go smoke my cigarettes around the corner. I never got no smoking apron or cigarette holder. I would like to have a smoking apron. When asked where he stores his smoking paraphernalia (cigarettes and lighter), the resident stated, I get it from someone I know outside. When asked about the facility's smoking policy or smoking contract, Resident #10 stated, I don't know nothing about a policy or contract, they just tell us don't smoke. During a face-to-face interview on 04/17/25 at 11:33AM, Employee #31 (assigned LPN) stated that she did not know Resident #10 was a smoker. I have never seen cigarettes on him. I know the resident goes downstairs but I don't know what he does there. When asked about the facility's smoking policy the employee stated, I don't know the specifics. I know that the residents are not allowed to smoke. During a face-to-face interview on 04/17/25 at 11:35 AM, Employee #32 (assigned CNA) stated, I am not aware if [Resident #10] is a smoker. I have never found or seen any smoking materials in his possession. When asked about the facility's smoking policy, the employee stated that she was not aware of one. During a face-to-face interview on 04/17/25 at approximately 12:00 PM, Employee #2 (DON) acknowledged that Resident #10 is a known cigarette smoker and that facility staff failed to ensure that he was smoking safely as evidenced by not providing the resident with the required adaptative equipment needed (smoking apron and cigarette holder). These findings resulted in an Immediate Jeopardy being called on 04/17/25 at 3:36 PM. On 04/17/25 at 8:28 PM, the facility's Administrator provided the State Agency Survey Team with an acceptable Plan of Removal that addressed the immediate concerns with residents' smoking. The plan included the following interventions: Resident-Specific Interventions - Resident #10: Will be reassessed using smoking safety assessment; smoking apron and /or any identified smoking aid will be offered; care plan will be updated to reflect supervision needs and proper storage of paraphernalia. The residents will be educated on the revised smoking policy. This will be started on 4/18/25 - Resident #46: Will be reassessed using smoking safety assessment; smoking apron and /or any identified smoking aid will be offered; care plan will be updated to reflect supervision needs and proper storage of paraphernalia. The residents will be educated on the revised smoking policy. This will be started on 4/18/25 - Resident #80: Will be reassessed using smoking safety assessment; smoking apron and /or any identified smoking aid will be offered; care plan will be updated to reflect supervision needs and proper storage of paraphernalia. The residents will be educated on the revised smoking policy. This will be started on 4/18/25 - Resident #92: Will be reassessed using smoking safety assessment; smoking apron and /or any identified smoking aid will be offered; care plan will be updated to reflect supervision needs and proper storage of paraphernalia. The residents will be educated on the revised smoking policy. This will be started on 4/18/25 - Resident #48: Will be reassessed using smoking safety assessment; smoking apron and /or any identified smoking aid will be offered; care plan will be updated to reflect supervision needs and proper storage of paraphernalia. The residents will be educated on the revised smoking policy. This will be started on 4/18/25 Facility-Wide Interventions - We will conduct a facility-wide audit of all residents to identify active smokers starting 4/18/25. Smoking Policy will be revised as of 4/18/25. - We will complete the Smoking Safety Assessment on all identified smokers starting 4/18/25. We will update and individualize the care plans for each smoker to reflect supervision needs, location, and supplies needed to assure safe smoking based on their assessment findings starting 4/18/25. If smoking paraphernalia is found, we will immediately attempt to confiscate all smoking paraphernalia. If unable to confiscate the smoking materials, social services, recreation services, ombudsman and/or the police will be involved. All items confiscated will be labeled and logged. - We will reinforce the prohibition of smoking materials in resident rooms or on persons with residents and staff. This will be started 4/18/25. - Residents identified as smokers will be educated starting 4/18/25 on the updated smoking policy, smoking process and a smoking contract. Staff Education and Competency Validation - 70 percent of current staff (clinical, non-clinical, and agency staff) will receive in-service training on the smoking policy, safe smoking practices, resident supervision, and emergency response protocols starting 4/18/25. The goal will be 100% of staff to receive training. - Training will include the revised smoking policy and procedure. Nursing staff or designee will be assigned to monitor known smokers in the designated smoking area - Smoking binders will be placed on all floors and the security desk to help identify residents who smoke. Implementation of Systems and Monitoring Processes - We will develop a daily room audit tool that includes permission to inspect for smoking paraphernalia (lighter, cigarettes, etc.). This will be completed by nurse aide or designee. - We will establish and enforce a smoking materials storage protocol; only designated staff will have access. - We will create a resident smoking log and supervision documentation tool that includes time in/out, safe smoking supplies offered/accepted or declined. - We will assign a designated Smoking Safety Supervisor per shift. - We will complete monthly audits added to the QAPI Committee agenda for compliance tracking. Designated Smoking Area Protocols - We will enforce the use of a designated smoking area (outside to the left of the main entrance on the ground level)- Smoking area will include a fire extinguisher (in close proximity), fire blanket, will post no-smoking signage, and will have locked cart for smoking materials at the security desk). - All residents who smoke will have to sign in/out and will be supervised by a nursing assistant or other clinical staff. - Smoking aprons will be offered and documented on the smoking log. Return of smoking materials will also be documented on the log. - Residents will only be able to access smoking materials during scheduled supervised times. (10am,1 pm, 4pm, 7pm and 10pm). Completion date for Immediate Jeopardy Compliance - 4/21/25 After the plan was verified, the IJ was removed on April 24, 2025, at 1:50 PM while the survey team was onsite. Based on observations, record reviews and staff interviews, for six (6) of 49 sampled residents, facility staff failed to ensure that resident environments were free of accident hazards as evidenced by: (1) Four portable space heaters observed in Residents' #10, #48, #87, and 92 rooms; and (2) Inadequate supervision and unsafe smoking practices for Residents' #10, #46, #80, and #92 who were identified by staff as smokers. An Immediate Jeopardy, related to space heaters in resident rooms, was identified on 04/13/25 at 1:34 PM. The facility provided a plan of action to address the immediacy on 04/13/25 at 5:04 PM that was accepted. After the plan was verified, the IJ related to space heaters was removed on 04/22/25 at 9:34 AM, while the survey team was onsite. After the removal of immediacy, the deficient practice remained at a scope and severity of E. An Immediate Jeopardy, related to inadequate supervision and unsafe smoking practices were identified on 04/17/25 at 3:36 PM, The facility provided an acceptable Plan of Removal to address the immediate concerns on 04/17/25 at 8:28 PM. While on site the State Survey Team, verified that the facility's Plan of Removal interventions for inadequate supervision and unsafe smoking practices were implemented. The IJ was then removed on 04/24/25 at 1:50 PM. After removal of the immediate concerns, the deficient practice remained at a scope and severity of D. The findings included: 1. Review of the facility's Electrical Appliances policy dated 05/24/24 documented: Portable space heaters are not allowed in resident areas. 1a. Resident #87 was admitted to the facility on [DATE] with multiple diagnoses that included: Chronic Respiratory Failure with Hypoxia and Hypercapnia, Asthma, and Muscle Weakness. Review of the resident's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which showed that facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 11, indicating mild cognitive impairment. There was no functional impairment in range of motion and in upper extremities that was noted. During a unit tour of the 5th floor on 04/13/25 at 6:50 AM, a portable space heater was observed in use and blowing hot air on Resident #87. The space heater was noted to be approximately less than one foot away from the resident's bed, on top of a gray, plastic wash basin, that was sitting on top of the bedside drawer. During a face-to-face interview at the time of the observation, Employee #5 (assigned Licensed Practical Nurse/LPN) was asked why there was a space heater in the resident's room. The employee responded, [Resident #87] was transferred to this room with the space heater about three (3) days ago. She gets cold. I think her family bought it for her. When asked if she was aware that space heaters were not permitted in resident care areas, the employee did not respond. During subsequent observations of all resident rooms, on all floors, portable space heaters were noted plugged in for use on the fourth and fifth floors respectively for the following residents: #92, #10, and #48. 1b. Resident #10 was admitted to the facility on [DATE] with multiple diagnoses that included: Muscle Weakness, Paraplegia, and Nicotine Dependence. Review of the resident's medical record revealed the following a Quarterly Minimum Data Set (MDS) assessment dated [DATE] that showed facility staff coded: a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition and had functional limitation impairment in range of motion on one side for upper extremities. 1c. Resident #92 was admitted to the facility on [DATE] with multiple diagnoses that included: Paraplegia, Polyneuropathy, Generalized Muscle Weakness, and Need for Assistance with Personal Care. Review of the resident's medical record revealed the following a Quarterly Minimum Data Set (MDS) assessment dated [DATE] that showed facility staff coded: a BIMS summary score of 15, and functional limitation impairment in range of motion on both upper extremities. 1d. Resident #48 was admitted to the facility on [DATE] with diagnoses that included Quadriplegic C5-C7 and Vascular Myelopathy. Review of Resident #48's medical record revealed the following a Quarterly Minimum Data Set (MDS) assessment dated [DATE] that showed facility staff coded a BIMS summary score of, 15, and impairments in functional limitations in range of motion impairment on both sides for upper and lower extremities. It should be noted that Residents' #87, #48, #84, #10 were non-ambulatory. A face-to-face interview was conducted on 04/13/25 at 10:22 AM with Employees #3 (Registered Nurse/RN Supervisor) and Employee #4 (Plant Operations Supervisor). Employee #3 stated that she was not aware that space heaters were not allowed in resident rooms. Employee #4 acknowledged the findings and stated that space heaters are not allowed in resident rooms. These findings resulted in determination of Immediate Jeopardy on 04/13/25 at 1:34 PM. The facility's Administrator provided a plan of action to address the immediacy on 04/13/25 at 5:04 PM that was accepted and included: 1. Immediate Removal of Hazard Facility staff will be sent to each unit simultaneously to the rooms identified by surveyors to remove the portable space heaters within 15 minutes of notification of the Immediate Jeopardy. All other resident rooms will be checked and any portable space heaters found will be removed immediately on 04/13/25. 2. Environmental Sweep A facility-wide sweep will be conducted by the Maintenance Director and Administrator within 1 hour to identify any other unauthorized electrical appliances or hazards. Documentation of the sweep, including date, time, and rooms assessed, will be completed and placed in the IJ response binder on 04/13/25. Any additional hazards found will be removed immediately, and residents will be educated as needed. 3. Policy Enforcement The facility's Electrical Appliances policy will be reviewed and updated to explicitly prohibit portable space heaters in all patient care areas on 04/13/2025. 4. Resident and Family Education All residents and their responsible parties will be provided with written and/or verbal education on prohibited appliances, including portable space heaters, starting on 4/13/2025. A robo call will be sent to every family member/POA on 04/13/25 regarding the prohibition of portable space heaters. 5. Staff Education All staff present here today on 04/13/25 including housekeeping, maintenance, dietary, nursing, and respiratory therapy will be educated on identifying and reporting unsafe resident practices and prohibited electrical appliances as of 4/13/2025. All other staff will be educated upon arrival before the start of their next shift on prohibited electrical appliances to include portable space heaters starting on 04/13/2025. We will complete at least 80% compliance by Wednesday, April 16, 2025, with a goal of 100%. 6. Date of Compliance April 16, 2025 The Survey Team verified that the plan of action to address the immediacy was in place. The Immediate Jeopardy related to space heaters in resident rooms was lifted on 04/22/25 at 9:34 AM while the survey team was onsite.

Based on observation, record reviews and staff interviews for one (1) of 39 sampled residents, facility staff failed to consistently assess and document changes in the skin of Resident #47 who developed an in-house, acquired pressure injury/ulcer that was first identified at an advanced stage (Stage 3). (Resident #47) These failures resulted in actual harm to Resident #47. The findings include: A policy titled, Prevention of Pressure Ulcers/Injuries with a revision date of 05/24/24 instructed staff to, Inspect the skin on a daily basis when performing or assisting with personal care or ADLs (activities of daily living); Identify any signs of developing pressure injuries (i.e., non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; Inspect pressure points (sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, etc.) .Moisturize dry skin daily; and Reposition resident as indicated on the care plan . 1. Resident #47 was admitted to the facility on [DATE] with multiple diagnoses including Quadriplegia, Encephalopathy, Chronic Respiratory Failure (Hypoxia) and Muscle Weakness. A quarterly Minimum Data Set assessment dated [DATE] documented that the Brief Interview for Mental Status summary score was blank indicating that the resident did not respond to the test questions. The resident was coded for bilateral impairment of upper and lower extremities and being totally dependent on staff for all activities of daily living, being at risk for developing pressure ulcers, being on a turning and repositioning program, and using a pressure reducing bed. Also, the resident's height was documented as 74 inches [6.1 feet] and weight was 176 pounds. A physician order dated 11/06/24 instructed, Aquaphor External Ointment (Emollient) apply to bilateral lower extremities topically two times a day for wound care. Off-load bilateral heel with off-loading device every shift for pressure redistribution .Turn and reposition every two hours using wedges or pillows for pressure redistribution every shift. A care plan with a review date of 11/07/24 documented in part, Focus- [Resident #47] is activity of daily living dependent secondary to Quadriplegia with incontinence of bladder and bowel with inability to communicate needs .Interventions - assess, record, report and treat for any abnormality to skin during incontinent care, dependent on 2 staff to provide bath/shower and turning and repositioning every 2 hours and as necessary .totally dependent on 1 staff for personal hygiene . A physician order dated 11/08/24 instructed, Perform skin assessments on shower days twice a week and notify MD of any new changes every Tuesday and Friday. A quarterly Braden Scale for Predicting Pressure Score Risk dated 11/21/24 documented that the resident had a score of 15 indicating that the resident was at risk for developing pressure ulcers. Progress notes dated 11/22/24 to 01/07/25, lacked documented evidence of an alteration in the skin integrity of Resident #47's left foot. Treatment Administration Records dated 11/22/24 to 01/07/25, licensed nursing staff documented that the following tasks were performed for the resident: Skin assessments (head-to-toe) conducted by licensed staff twice a week on shower days; Aquaphor ointment was applied to bilateral lower extremities twice a day; Turned and repositioned daily, every two hours; Bilateral heels were off loaded (elevated) with off-loading devices (wedges/pillows) daily, every shift. However, the facility staff failed to identify the resident's left foot pressure ulcer until 01/08/25 when it was an advanced stage (Stage 3). A Situation, Background, Assessment, Request (SBAR) form dated 01/08/25 at 7:29 PM signed by Employee #14 (LPN) documented in part, Discovery of wound on left lateral aspect of the left foot started on 01/08/25 . resident properly repositioned and turned every 2 hours for purpose of proper weight distribution and prevention of further skin injury. Nurse Practitioner notified of wound and wound consult placed and order obtained for treatment of wound . A wound care nurse practitioner progress note dated 01/09/25 at 7:23 PM documented in part, Reason for visit: new skin and wound consult .Patient with new stage 3 pressure injury to the left lateral distal foot . Lower Extremity Exam .Texture: dry, flaky, thickened, Perfusion: diminished pedal pulses, left foot cool to touch, Sensation: Bilateral lower extremity insensate, Associated Findings: generalized dryness . Wound Status: Odor Post Cleansing: None, Size: 1 cm (centimeters) x 0.8 cm x 0.2 cm. Calculated area is 0.8 sq (square) cm, Wound Base: 20% epithelial , 70% granulation , 10% slough , 0% eschar, Wound Edges: Attached Periwound: Fragile, Callous, Exposed Tissues: Subcutaneous, Exudate: Moderate amount of Serosanguineous .Treatment- cleanse wound with wound cleanser, apply Iodosorb (topical antiseptic ointment) to base of wound, secure with boarder gauze, change daily . An observation with the wound nurse on 04/22/25 at approximately 12:30 PM showed the resident lying in bed, awake, non-verbal, and well groomed. The resident had a dressing to the left foot. The dressing was dry and intact. When the wound nurse practitioner removed the dressing, the wound had no smell, was approximately 1 inch in width and no depth, red tissue in center with pink surrounding tissue. During a face-to-face interview on 04/22/25 at approximately 12:30 PM, Employee #35 (Nurse Practitioner - Wound Specialist) stated that staff informed him on 01/08/25 that the resident had a new wound on his left foot. On 01/09/25, he assessed the resident and determined that he had a Stage 3 pressure wound to the left lateral foot. Also, Employee #35 said that he requested a longer bed for the resident because the resident's left foot was pressing against the bed's footboard which likely contributed to pressure at the site of the pressure injury. As a result, Resident #47 subsequently was issued a new bed with an extended footboard. During a face-to-face interview on 04/30/25 at approximately 3 PM, Employee #14 (assigned LPN) stated that he should have documented the characteristics of the resident's wound (size, depth, color, odor) on the SBAR dated 01/08/25. Additionally, the employee said that he conducts head-to-toe-assessments skin assessments twice a week and as needed. And he ensures that the resident is turned and reposition every-two-hours daily and heels are always elevated off the mattress to prevent pressure. During a face-to-face interview on 04/30/25 at approximately 3:30 PM, Employee #10 (RN/Nurse Supervisor) reviewed the resident's medical record and said that she did not see documentation of a skin integrity issue with the resident's left foot before 01/08/25. During a face-to-face interview on 05/01/25 around 3:30 PM, Employee #36 (Central Supply Technician) indicated that he had received an electronic work order for a longer bed for Resident #47. According to the employee, he did not keep a copy of the work order and could not recall the exact date when he received it. However, he remembered that he provided the resident with a bed that extended at the foot portion on 02/18/25. Cross reference 22B DCMR Sec.3211.1(b)

Based on record reviews and staff interviews, facility staff failed to provide a training program or another practical manner to effectively communicate the standards, policies, and procedures of the compliance and ethics program to its entire staff. The findings included: On 05/05/25, the facility's education and training records for its Compliance and Ethics program were reviewed as part of an extended survey. The facility provided a binder from the educator that included the education and training records for staff in the facility for review. Inside of the binder was a table of education topics with the heading, 2024 SNF (Shared Nursing Facility) Skills Fair Training. In the first column of the table was a list of several training topics including Compliance and Ethics. In the column next to Compliance and Ethics, were the comments, Review and packet. Attached to the Skills Fair Training document was a September 19-20-2024, 24-page sign-in sheet with the signatures of some staff who attended the skills fair training, however there was no documented evidence to show that the educator provided a training program or another practical manner to effectively communicate the standards, policies, and procedures of the compliance and ethics program to its entire staff. In addition, there was no documentation to show that staff who were not present for the September 19-20, 2024, skills fair, received education and training for the facility's Compliance and Ethics program. The facility's educators were not available for interview on 05/05/25 to answer questions about the facility's education and training records. During a face-to-face interview on 05/05/25 at 9:15 AM, Employee#48/ Regional Director of Operations stated that The Compliance and Ethics training is usually completed during staff orientation and as part of the staff skills fair training that the facility has annually. Employee #48 then reviewed the facility's staff education and training binder, and the facility's administrative records, and stated that all she could find was the list of training topics for the 2024 SNF Specific Skills Fair Training and the sign-in sheets for Compliance and Ethics training. She commented further that she could not substantiate that the staff educator provided training on the facility's Compliance and Ethics program. During a face-to-face interview on 05/05/25 at 11:36 AM with members of the QAA Committee Employee #1/Administrator stated, The staff is not getting the education to the extent needed; The Director of Nursing (DON)and myself [Administrator] provide some of the education prn (as needed). A new facility educator was hired. The Employee has been here a few weeks and has done some training, but only remotely. We need to do a better job with our education of staff, and we need more availability of the training from the educator. We will look back into having an Educator onsite and meeting the needs of the facility to address it.

Based on record reviews and staff interviews, facility staff failed to show documented evidence of an effective training program for all staff, which includes, at a minimum, training on behavioral health care and services for its residents. The findings included: On 05/05/25, the facility's education and training records for were reviewed as part of an extended survey. The facility provided a binder from the educator that included the education and training records for staff in the facility for review. The binder showed no documented evidence of an effective training program for all staff, which included, at a minimum, training on behavioral health care and services for its residents. During a face-to-face interview on 05/05/25 at 9:15 AM, Employee #48/ Regional Director of Operations, stated that the behavioral health care and services for residents is usually completed during staff orientation and as part of the staff skills fair training that the facility has annually. Employee #48, then reviewed the facility's staff education and training binder, and the facility's administrative records, and stated that she did not see where the behavioral health care and services for residents was included as part of the annual SNF Specific Skills Fair. She commented further that she could not substantiate the staff educator provided education and training on the behavioral health care and services for its residents. During a face-to-face interview on 05/05/25 at 11:36 AM with members of the QAA Committee Employee #1 stated: The staff is not getting the education to the extent needed; The Director of Nursing and the Administrator provide some of the education prn (as needed). A new facility educator was hired. The Employee has been here a few weeks and has done some training, but only remotely. We need to do a better job with our education of staff, and we need more availability of the training from the educator. We will look back into having an Educator onsite and meeting the needs of the facility to address it.

Based on record reviews and staff interviews, facility staff failed to provide training that outlined and informed staff of the elements and goals of the facility's QAPI program. The findings included: On 05/05/25, the facility's education and training records were reviewed as part of an extended survey. The facility provided a binder from the educator that included the education and training records for staff in the facility for review. Inside of the binder was a table of education topics with the heading, 2024 SNF (Shared Nursing Facility) Skills Fair Training. In the first column of the table was a list of several training topics including QAPI (Quality Assurance and Performance Improvement Plan and Participation. In the column next to QAPI were the comments, Review and packet. Attached to the Skills Fair Training document was a September 19-20-2024, 24-page sign-in sheet with the signatures of some staff who attended the skills fair training, however there was no documented evidence to show that the educator provided a review or a packet for QAPI to facility staff as part of their education and training. In addition, there was no documentation to show that staff who were not present for the September 19-20, 2024, skills fair, received QAPI training. The facility's educators were not available for interview on 05/05/25 to answer questions about the facility's education and training records for staff. During a face-to-face interview on 05/05/25 at 9:15 AM, Employee #48/Regional Director of Operations, stated that, All staff are required to receive QAPI training. QAPI training is usually completed during staff orientation and as part of the staff skills fair training that the facility has annually. Employee #48 then reviewed the facility's staff education and training binder, and the facility's administrative records, and stated all she could find was the list of training topics for the 2024 SNF Specific Skills Fair Training and the sign-in sheets for QAPI training. She commented further that she could not substantiate that the staff educator provided training that outlined and informed staff of the elements and goals of the facility's QAPI program, or how to facility staff could communicate concerns, problems or opportunities for improvement to the facility's QAA (Quality Assessment and Assurance Committee). During a face-to-face interview on 05/05/25 at 11:36 AM with members of the QAA Committee Employee #1/Administrator, stated: The staff is not getting the education to the extent needed. The Director of Nursing (DON) and myself [Administrator] provide some of the education prn (as needed). A new facility educator was hired. The Employee has been here a few weeks and has done some training, but only remotely. We need to do a better job with our education of staff, and we need more availability of the training from the educator. We will look back into having an Educator onsite and meeting the needs of the facility to address it.

Based on record reviews and staff interviews, facility staff failed to ensure that staff members were educated on the resident's rights and the facility's responsibilities to properly care for its residents, as set forth at §483.10, respectively. The findings included: A review of the Facility's Assessment updated 12/03/24, that documented: .Section 3.4 Staff Training/Education and Competencies. We only hire individuals that are eligible to work in The District of Columbia, currently using temporary nursing assistant(s). Department and job specific competencies are completed during orientation and reviewed annually. Competencies follow a pattern of requirements for certification and licensure renewal and trends of events within the facility and industry as a whole .List of competencies include- tracheostomy, ventilator, Enteral Tube feeding, ostomy, IVs (intravenous), TPN, (total parenteral nutrition) vital signs, weight taking, height measuring, oxygen, suctioning, systems assessment, turning and repositioning, SBAR (Situation, Background, Assessment, Request) Communication Forms, Care plan, change in condition communications, computer documentation and changes in condition and reporting, complaint management, drains, referrals, appointment making, assistance with ADLs (activities of daily living skills), wound care, IDT (interdisciplinary team) assessments and isolation. A review of the facility's policy entitled, Resident Rights, (revised 05/24/24 ) documented .Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights. On 05/05/25, the facility's education and training records for Residents' Rights were reviewed as part of an extended survey. The facility provided a binder from the educator that included the education and training records for staff in the facility for review. Inside of the binder was a table of education topics with the heading, 2024 SNF (Shared Nursing Facility) Skills Fair Training. In the first column of the table was a list of several training topics including Resident Rights and Facility Responsibilities. In the column next to Residents Rights were the comments, Review and packet and HealthStream. Attached to the Skills Fair Training document was a September 19-20-2024, 24-page sign-in sheet with the signatures of some staff who attended the skills fair training, however there was no documented evidence that showed what the HealthStream education/training for Residents Rights consisted of and there was no documented evidence to show that the educator provided a review and packet for Resident Rights to facility staff as part of their education and training. In addition, there was no documented evidence that staff who were not present for the September 19-20, 2024, skills fair, received the training. The facility's educators were not available for interview on 05/05/25 to answer questions about the facility's education and training records. During a face-to-face interview on 05/05/25 at 9:15 AM, Employee #48/Regional Director of Operation stated, All staff receive education and training on Residents Rights that they during orientation before they are assigned to the floor and as part of the staff skills fair training annually. Employee #48 then reviewed the facility's staff education and training binder, and the facility's administrative records, and stated that all she could find was the list of training topics for the 2024 SNF Specific Skills Fair Training and the sign-in sheets. She commented further that she could not substantiate what specific information the staff educator provided for review or in the education packet for Resident Rights. During a face-to-face interview on 05/05/25 at 11:36 AM with members of the QAA Committee Employee #1/Administrator, The staff is not getting the education to the extent needed; the Director of Nursing and myself (Administrator) provide some of the education PRN (as needed). A new facility educator was hired. The Employee has been here a few weeks and has done some training, but only remotely. We need to do a better job with our education of staff, and we need more availability of the training from the educator. We will look back into having an Educator onsite and meeting the needs of the facility to address it. Cross reference 22B DCMR Sec 3214.4

Based on record reviews and staff interviews, facility staff failed to show documented evidence of its Required In-Service Training for Nurse Aides. The findings included: A review of the Facility's Assessment updated 12/03/24, that documented: .Section 3.4 Staff Training/Education and Competencies. We only hire individuals that are eligible to work in The District of Columbia, currently using temporary nursing assistant(s). Department and job specific competencies are completed during orientation and reviewed annually . On 05/05/25, the facility's education and training records for the required in-service training for Nurse Aides were reviewed as part of an extended survey. The facility provided a binder from the educator that included the education and training records for staff in the facility for review. The binder contained the following education and training provided by the educator for the facility's Certified Nurse Aides (CNAs) in 2024: 1)Documentation news article and monthly test; No staff sign-in sheet was attached: (June); 2) Reporting to the Nurse, news article and monthly test; No staff sign-in sheet was attached (July); and, 3) Skin and Wound Observation news article and monthly test; No staff sign-in sheet was attached (August). Of note, the facility's education and training binder showed documented evidence of its required in-service training for Nurse Aides for only three (3) months out of 12. The facility's educators were not available for interview on 05/05/25 to answer questions about the facility's education and training records. During a face-to-face interview on 05/05/25 at 9:15 AM, Employee# 48/Regional Director of Operations stated, The the CNAs receive the required in-service training during staff orientation before they are assigned to the floor and annually at the SNF Specific Skills Fair. Employee #48 then reviewed the staff education and training binder, and the facility's administrative records, and stated that all she could find was the training that the educator provided for June, July and August, 2024. She commented further that she could not substantiate that the staff educator provided all of the required in-service training for the CNAs. During a face-to-face interview on 05/05/25 at 11:36 AM with members of the QAA Committee Employee #1 stated, The staff is not getting the education to the extent needed; The Director of Nursing and the Administrator provide some of the education prn (as needed). A new facility educator was hired. The Employee has been here a few weeks and has done some training, but only remotely. We need to do a better job with our education of staff, and we need more availability of the training from the educator. We will look back into having an Educator onsite and meeting the needs of the facility to address it.

5. Resident #91 was admitted to the facility on [DATE] with multiple diagnoses that included: Interstitial Pulmonary Disease, Type 2 Diabetes Mellitus and Chronic Respiratory Failure. Review of the resident's medical record revealed the following: An admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 13, indicating intact cognitive response. Physician's orders dated 02/10/15 directed, Established [central] line - Change dressing Q (every) 7 days, every night shift every Monday for IV-line care; Change dressing as needed if not intact or soiled as needed for IV care; Observe insertion site every shift for redness, warmth, swelling, drainage, coldness or irritation, every shift for IV care. Review of the April 2025 Treatment Administration Record (TAR) showed that on 04/07/25, facility staff documented a check mark and their initials to indicate that the resident's central IV-line dressing was changed during the night shift. During an observation on 04/13/25 at 2:28 PM, Resident #91 was noted with a left upper arm central IV line with a dressing that was dated 04/03/25. Review of the resident's medical record on 04/18/25 showed no documented evidence that facility staff developed a care plan with goals and interventions to address Resident #91's use of a left upper arm central IV line. During a face-to-face interview on 04/18/25 at 11:32 AM, Employee #6 (6th Floor Unit Manager) reviewed the resident's medical record, acknowledged the findings and stated that a care plan address Resident #91's use of a left upper arm central IV line will be developed. Cross reference 22B DCMR Sec. 3210.4(a) 2. Resident #65 was admitted to the facility on [DATE] with diagnoses that included: Traumatic Brain Injury with Loss of Consciousness of Unspecified Duration, Chronic Respiratory Failure; Traumatic Spinal Cord Dysfunction; ) Quadriplegia, Contracture of the Knee (Unspecified), Contracture of the Foot (Unspecified); Neuromuscular Dysfunction Of Bladder; Urinary Tract Infection; Encounter for Attention to Gastrostomy; Encounter for Attention to Tracheostomy, Anxiety Disorder and Depression. A review of Resident #48's medical record revealed: An admission MDS (Minimal Data Set) assessment dated [DATE] that documented the Resident had a Brief Interview for mental Status (BIMS) summary score of, 14 indicating that the Resident had intact cognition. In addition, the resident was coded for: impairment status on both sides to the upper and lower extremities; dependent status on for all (activities of daily living skills (ADLs) including turning and repositioning, having a fall in the last month prior to admission, having recent spinal surgery, having a gastrostomy tube, having a tracheostomy, and receiving speech and occupational therapies. An SBAR dated 01/02/25 that documented: Situation: Rt (Right) plantar foot swollen. Order for X-Ray of Rt plantar foot; Assessment (Registered Nurse/RN) or Appearance (Licensed Practical Nurse/LPN): Swollen Rt plantar foot; Request/Nursing Notes: Order given by NP (Nurse Practitioner) on duty for X-ray of the right plantar foot to rule out fracture. Resident aware, RP/Friend [Name of resident representative] notified . An X ray Report dated 01/02/25 that documented: Clinical History: [Resident] presents for fracture. Technique: 3 views of the right foot Comparison: None. Findings: Diffuse soft tissue swelling about the right foot. Diffuse osteopenia. Cannot exclude an acute fracture on this . A General Progress Note dated 01/03/25 at 6:57 PM that documented: Resident lab result received findings stated 'Diffuse osteopenia. Cannot exclude an acute fracture on this limited osteopenic study. Suggestion of a fracture of the distal fibula. No dislocation.' [Name of Medical Director] was called by the 4th floor unit manager . She stated 'We need to send him to orthopedics. I don't think that is acute. [An] elective consultation arrangement will be made. I will contact [Rehab Director's Name] to put a boot on it. A care plan initiated on 01/03/25 that documented:: [Name of Resident #68] has Diffuse osteopenia. Cannot exclude an acute fracture on this limited osteopenic study . No dislocation. Goal: Resident will verbalized reduction of pain by the next review date. Interventions initiated 01/04/25: Elective consultation arrangement will be made by MD ; Log roll resident during transfer and observe foot precaution; MD will follow up with rehab for boot . A revised care plan dated 01/03/25 that documented: [[Name of Resident #68] has diffuse osteopenia and at risk for fracture r/t x-tray of the right foot dated 01/03/2025 Date Intervention included: .Orthopedic consult; Provide with pillows, etc. to help maintain comfortable position; PT (Physical Therapy) evaluation and treatment as ordered. 01/06/25 physician's order that directed: PT (Physical Therapy) Consult and prn (as needed), right foot boot for immobilization, distal fibula fracture. A Physical Therapy Encounter Note dated 01/09/25 that documented: . Pt was seen in room and was given foot brace to wear to immobilize ankle. 01/09/25 Physical Therapy Encounter Note: . Pt (Patient) was seen in room and was given foot brace to wear to immobilize ankle. Pt tolerated foot brace well and NP (Nurse Practitioner) also said it was good for patient . A further review of Resident# 65's comprehensive care plan showed no documented evidence that facility developed or implemented a care plan with a focus, goals or interventions for the resident's right foot boot for immobilization. During a face-to-face interview on Employee #21, Director of Rehab stated that the Resident was given the immobilization boot on 01/09/25 from phyiscal therapy, and a care plan for the boot should have been implemented then. During a face-to-face interview on 05/01/25 at 1:25 PM Employee #2 Director of Nursing (DON) stated that the Unit supervisors, unit managers, and the DON and all members of the disciplinary team were responsible for implementing the care plans. She further commented that since the fourth floor had currently had no unit Manager, implementing and updating resident care plans was primarily her responsibility. The Employee then acknowledged that a care plan for Resident # 65's right foot immobilization boot should have been implemented. 3. Resident #68 was admitted to the facility on [DATE] with diagnoses that included: History of Falling; Acute Respiratory Failure; Displaced Intertrochanteric Fracture of Right Femur, Atrial Fibrillation; Chronic Hepatitis, Orthostatic Hypotension, Restlessness and Agitation. A review of Resident #68's medical record revealed: An admission annual MDS (Minimal Data Set) assessment dated MDS 03-11-24 which documented that the Resident had a Brief Interview for mental Status (BIMS) summary score of, 05 indicating that the Resident had severely impaired cognition. In addition the assessment documented that Resident's preferred language was Spanish and the Resident needed and wanted an interpreter to communicate with a doctor or health care staff. An annual MDS (Minimal Data Set) assessment dated MDS 02-28-25 which documented that the Resident had a Brief Interview for mental Status (BIMS) summary score of, 13 indicating that the Resident had intact cognition. In addition, the assessment documented that Resident's preferred language was Spanish and the Resident needed and wanted an interpreter to communicate with a doctor or health care staff. During an initial tour of the 4th floor unit on 04/13/25 at 8:09 AM, a face-to-face interview was conducted with Resident #68 and a Spanish speaking interpreter (via the facility's language interpreter phone line service), the Resident stated he spoke very little English and he preferred to speak Spanish. The resident added that he could communicate with the staff, but sometimes he didn't understand what the staff and he was not sure if they could understand him. When asked if facility staff offered use of via Spanish interpreter via the language line he said, No, not so much. My brother speaks English, so if something happens I let my brother know. He talks to the facility staff. During an initial tour of the 4th floor unit on 04/13/25 at 8:25 AM, a face-to-face interview was conducted with Employee #46 /Licensed Practical Nurse assigned to Resident #68. When asked if the Employee used the language line to communicate with the Resident, she stated, No. The Resident is Spanish, but he understands and speaks English. A review of Resident #68's comprehensive care plan lacked documented evidence that facility staff implemented a care plan for the resident's preference to use a Spanish speaking interpreter when communicating with a doctor or health care staff. During a face-to-face interview on 05/01/25 at 1:25 PM Employee #2 stated since the fourth floor had currently had no unit Manager, she was primarily responsible for implementing and updating resident care plans. The Employee then stated and acknowledged that although Resident #68 understands and speaks some English, a care plan for the Resident's preference to use an interpreter when communicating with a doctor or health care staff should have been developed, implemented and included in the resident's person-centered comprehensive care plan. 4. Resident #84 was admitted to the facility with the following diagnoses: Metabolic Encephalopathy; Quadriplegia;Traumatic Spinal Cord Dysfunction; Chronic Respiratory Failure; Dependence On Respirator [Ventilator] Status; Encounter for Attention to Tracheostomy; Dysphagia; Encounter for Attention to Gastrostomy, Anxiety Disorder and Depression. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #84 had a Brief Interview for Mental Status (BIMS) of, 15 indicating that the Resident had intact cognition. In addition, the resident was coded as having impairment s on both sides for the upper and lower extremities, limited range of motion; was dependent on staff for all ADLs (activities of daily living) including, had an indwelling urinary catheter, had a urinary tract infection within past 30 days of the assessment and had received antibiotic treatment. An SBAR Communication Form dated 01/02/25 that documented: Situation: Resident was noted with blood in Foley bag .Request/Nursing Notes: Patient was noted with blood in Foley bag, he denied pain or discomfort on the lower abdomen, abdomen soft, non-distended, temp of 98.0. MD (Medical Director) notified, after assessment, new order for UA (urinalysis) C/S (culture and specimen). RP (Representative) at the bedside made aware A physician's order dated 01/04/25 that directed: Bactrim DS Oral Tablet 800-160 MG (Sulfamethoxazole-Trimethoprim) Give 1 tablet via PEG-Tube (percutaneous endoscopic gastrostomy) every 12 hours for UTI (urinary tract infection)for 7 Days. A physician's order dated 01/07/25 that directed: Change 18Fr Foley catheter, tubing and drainage bag monthly. every night shift starting on the 7th and ending on the 7th every month. A physician's order dated 02/10/25 that directed: Foley catheter care q shift and record out put. every shift. An SBAR Communication Form dated 02/11/25 that documented: Situation: Sediments in urine .Request/Nursing Notes: Sediment noted in the urine bag, resident denied pain or abdominal discomfort. NP notified, order for Urinalysis Complete, urine culture. A review of Resident #84's comprehensive care plan lacked documented evidence that facility staff developed and implemented a comprehensive patient centered care planned that included a focus, goal, and interventions for the Resident's indwelling urinary catheter. During a face-to-face interview on 05/01/25 at 1:25 PM Employee #2 stated since the fourth floor had currently had no unit Manager, she was primarily responsible for implementing and updating resident care plans. The Employee then acknowledged that a care plan for the Resident #84's indwelling urinary catheter care should have been developed, implemented, and included in the resident's person-centered comprehensive care plan. Based on observations, interviews, and record reviews, for five (5) of 49 sampled residents, the facility staff failed to develop and/or implement care plans with goals and interventions to address: (1) Resident 38's use of a mechanically altered diet; (2) Resident#65's use of an orthotic foot brace for immobilization after the resident fractured his right foot; (3). Resident #68's preference to use an interpreter when communicating with a doctor or health care staff; 4) Resident #84's use of an indwelling urinary catheter; and (5) Resident # Resident #91's use of a left upper arm central intravenous (IV) line. (Residents #38, #65, # 68, #84, and #91) The findings included: 1. Resident #38 was readmitted to the facility on [DATE] with multiple medical diagnoses that included Dysphagia following Cerebral Infarction, Hemiplegia, Oropharyngeal Disease. Physician order dated 02/12/24 for Resident #38 instructed, Pleasure Feed Diet-Soft and Bite-Sized Texture (mechanically altered diet) .Assist feed, small bites/sips, slow rate intake, alternating consistencies. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented in part that the resident has a Brief Interview for Mental Status (BIMS) summary score of 01, indicating that the resident cognitive status was severely impaired. Review of resident's care plans lacked documented evidence that the facility's staff developed a care plan to address the resident's mechanically altered diet and instruction for feeding assistance from staff. During an observation on 04/22/25 at approximately 11:30 AM, Resident #38 was sitting in bed at a 90- degree with a lunch tray in front of him on a bedside table. Additionally, Employee # 11 (assigned CNA) was standing by the side of the resident's bed preparing to feed the resident. During a face-to-face interview on 04/22/25 at approximately 11:30 AM, Employee #10 (RN/Nursing Supervisor) stated that she did not see that a care plan had been developed to address the resident's mechanically altered diet.

Based on record review and staff interview, five (5) of 49 residents sampled, facility staff failed to have documented evidence that they provided information to the residents and/or their representatives (RP) regarding their right to formulate or refuse an advanced directive. Residents #87, #56, #91, #74, and #73. The findings included: Review of the facility's Advanced Directives policy dated 05/24/24 documented: - Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advanced directive if he or she chooses to do so. - If the resident is incapacitated and unable to receive information about his or her right to formulate an advance directive, the information may be provided to the resident's legal representative. - Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record. - If the resident indicates that he or she has not established advanced directives, the facility staff will offer assistance in establishing advanced directives. 1. Resident #87 was admitted to the facility on [DATE] with multiple diagnoses that included: Encephalopathy, Chronic Respiratory Failure with Hypoxia and Hypercapnia. Review of the resident's medical record revealed the following: A face sheet that showed that listed the resident's daughter as her responsible party (RP), care conference person, emergency contact #1 and next of kin. A care plan focus area, last revised on 03/11/25 documented: [Resident #87] end of life wishes to remain a full code. Goal(s): Interdisciplinary team (IDT) team will honor [Resident #87's] wishes for end-of-life care. Interventions: Assist with pre-burial needs upon request; Honor spiritual and cultural wishes Inform resident of memorial services within the facility via flyer; Offer 5 Wishes (the facility's advanced directives form) quarterly. Review of Resident #87's medical record on 04/14/25 showed no documented evidence that the facility staff offered Resident #87's RP information to formulate or refuse to formulate an Advanced Directive. 2. Resident #56 was readmitted to the facility on [DATE] with multiple diagnoses that included: Amyotrophic Lateral Sclerosis (ALS) and Chronic Respiratory Failure with Hypoxia. Review of the resident's medical record revealed the following: A face sheet that listed the resident's sister listed as her RP, care conference person and emergency contact #1. 01/14/25 at 12:20 PM Care Conference Note: - Care plan meeting was held for the resident. - The resident is alert, oriented, and communicates using an assistive device. - The resident's sister participated by phone. - Will remain full code. - Five Wishes were offered to resident and placed in her room per her request. A care plan focus area last revised on 03/14/25 documented: [Resident #56] end of life wishes are to remain a full code. Goal(s): IDT team will honor [Resident #56's] wishes for end-of-life care. Interventions: Honor spiritual and cultural wishes; Offer 5 Wishes quarterly. Review of Resident #56's medical record on 04/14/25 showed no documented evidence that the facility staff offered Resident #56 or her RP information to formulate or refuse to formulate an Advanced Directive. 3. Resident #91 was admitted to the facility on [DATE] with multiple diagnoses that included: Interstitial Pulmonary Disease, Type 2 Diabetes Mellitus and Chronic Respiratory Failure. Review of the resident's medical record revealed the following: A face sheet that showed that she was her on responsible party. An admission Minimum Data Set (MDS) assessment dated [DATE] showed that facility staff coded: adequate hearing; clear speech; makes self-understood; understands others; and a Brief Interview for Mental Status (BIMS) summary score of 13, indicating intact cognitive response. A care plan focus area revised on 03/17/25, [Resident #91] end of life wishes to be a full code, had interventions that included: assist with pre-burial needs upon request; honor spiritual and cultural wishes; and offer 5 Wishes quarterly. Review of the resident's medical record on 04/14/25 showed no documented evidence that the facility staff offered Resident #91 information to formulate or refuse to formulate an Advanced Directive. 4. Resident #74 was admitted to the facility on [DATE] with multiple diagnoses that included: Anoxic Brain Injury, Chronic Respiratory Failure with Hypoxia and Type 2 Diabetes Mellitus. Review of the resident's medical record revealed the following: A face sheet that listed the resident's daughter as her RP, care conference person and emergency contact #1. A care plan focus area revised on 04/07/25 documented: Family wishes for [Resident #74] to be a do not resuscitate (DNR). Goal: IDT team will honor family end of life wishes as a communicated by family. Interventions: Provide advanced care planning information to family; Provide spiritual care in accordance with family's faith; Review 5 Wishes with resident and family quarterly. Review of the resident's medical record on 04/14/25 showed no documented evidence that facility staff offered Resident #74's RP information to formulate or refuse to formulate an Advanced Directive. 5. Resident #73 was admitted to the facility on [DATE] with multiple diagnoses that included: Anoxic Brain Injury, Chronic Respiratory Failure, and Adult Failure to Thrive. Review of the resident's medical record revealed the following: A face sheet that listed that she had a had a legal guardian who is her RP and emergency contact #1. A care plan focus area, last revised on 0317/25 documented: Guardian end of life wishes for the resident to remain a full code. Goal: IDT team will honor the wishes for end of life care. Interventions: Honor spiritual and cultural wishes; Offer 5 Wishes quarterly. Review of Resident #73's medical record on 04/14/25 showed no documented evidence that the facility staff offered the resident's guardian information to formulate or refuse to formulate an Advanced Directive. During a face-to-face interview on 04/14/25 at 12:17 PM, Employee #18 (Director of Social Services) acknowledged the findings and stated, I leave the advanced directive form (5 wishes) in the room for the resident or their RP. Once it's filled out, the resident or the family will give us (Social Services Department) a call to come get it. When asked who follows up if the advanced directive is not returned to the Social Services Department, Employee #XX stated that there is no follow-up done by him or anyone else in the Social Services Department if the Advanced Directive forms are not completed by the resident or their family/representative. Cross Reference 22B DCMR Sec. 3231.12

Based on observations, record reviews and staff interviews for one (1) of 49 sampled residents, facility staff failed to provide documented evidence that one resident's bedrails were not being used as a restraint for a non-ambulatory, cognitively impaired resident who required extensive assistance with bed mobility and transfers. Resident #308. The findings included: A facility document titled 'Physical Restraint Application' with a review date of October 2010 documented the following: Definition - Physical restraints are defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body Documentation - The following information should be recorded in the resident's medical record: 1. The date and time the restraint was applied. 2. The name and title of the individual(s) who applied the restraint. 3. The type of physical restraint applied. 4. The specific reason the restraint was applied. 5. The length of time the restraint will be used. 6. Each time the device is released for resident exercise, toileting, and position change. 7. Each time the resident is monitored, per facility policy. 8. All assessment data (e.g., bruises, rashes, sores, etc.) observed during the procedure. 9. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 10. Any problems or complaints made by the resident related to the restraint application. 11. If the resident refused the treatment and the reason(s) why. 12. The signature and title of the person recording the data. A review of Resident #308's medical record revealed: A siderail assessment dated [DATE] documented, Yes - Involuntary or voluntary movement where it is observed that body parts are able to touch or roll into side rails with a 2 person turn and reposition; Yes - Resident unable to maintain positioning in bed as placed by staff with the use of regular pillows. A physician's order dated 02/12/25 documented, SIDE RAILS 1/4 (one quarter) EVERY SHIFT AS ENABLER TO PROMOTE BED MOBILITY every shift. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff marked No that indicated that they were unable to conduct the brief interview for mental status. It should also be noted that the MDS revealed that the resident had impairment on both sides to upper and lower extremities; was dependent on staff for rolling left and right; and required 2+ person assist for bed mobility, transfers, and toileting. During an observation conducted of the resident's room on 04/13/25 at approximately 9:00 AM, the resident was observed lying in bed with all four (4) bedrails in the upward position. During a subsequent observation conducted on 04/22/25 at approximately 12:00 PM, the resident was observed lying in bed with all four (4) bedrails in the upward position. It should be noted that there was no documented evidence in Resident #308's medical record stating that the resident should have all four (4) bedrails in use and in the upward position. During a face-to-face interview conducted on 04/23/25 at approximately 8:45 AM, Employees' #1 (Administrator) and #2 (Director of Nursing) both acknowledged the findings. Employee #1 stated, We don't have a bedrail policy, because the standard is that we only use two (2) siderails up for all of the beds, otherwise it is entrapment and also a restraint and Employee #2 stated, He was transferred here from LTACH (Long-Term Acute Care Hospital) in that bed to accommodate his size, but he shouldn't have the two (2) siderails at the bottom because four (4) siderails would be a restraint. He doesn't get up all, he can't move.

Based on record reviews and staff and family interviews, the facility failed to have documented evidence that verbal abuse of resident did not occur after receiving an allegation of staff-to-resident verbal abuse for one (1) of 1 sampled residents. (Resident #158) The findings included: Resident #158 was admitted on [DATE] with multiple diagnoses including Altered Mental Status, Muscle Weakness, and Psychotic Disorder. During a telephone interview related to different concern (Complaint DC~12827) on 04/25/25 at approximately 10 AM, the resident daughter (complainant) stated that Employee #39 (CNA) said, My mom was pistol in front of my mom. After the employee said my mom was afraid and wanted to go home. The resident's daughter then said, I told her [Employee #39] that I would not tolerate any mistreatment of my mom. And then the employee said that she could tell I was from the streets. Additionally, the resident's daughter said that she made the Administrator aware and she never saw Employee #39 again. It should be noted that the resident's daughter could not remember the specific date of the incident. On 04/24/25 at approximately 11 AM, a review of Resident #158's medical record and the facility's incident binder lacked documented evidence of alleged incident of verbal abuse. During a face-to-face interview on 04/29/25 at 6:20 AM, Employee #39 stated that the Administrator and Human Resource Director called her into a few months. The meeting was held because Resident #158's daughter said, I verbally abused her and her mom. The employee stated that she did not verbally abuse anyone. She was suspended for 2 day during the investigation and moved to a different floor when she returned to work. During a face-to-face interview on 04/29/25 at approximately 10 AM, Employee #1 (Administrator) stated that he remembered the incident. The employee said that they conducted an investigation and could not substantiate that staff-to-resident verbal abuse occurred. However, the employee said that the Human Resource's Director who no longer works for the facility had the investigation documents. And he was not able to locate them. Additonally, the employee said that Empployee #39 (CNA) was suspended while the investgation was conducted, and she was moved to another floor when she returned to work.

Based on record reviews and staff interviews for two (2) of 49 sampled residents, facility staff failed to report an incident of alleged staff-to-resident verbal abuse to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. Residents #62 and #40 The findings included: A facility policy titled 'Abuse Investigation and Reporting' with a review date of 05/24/24 documented the following: Policy Statement - All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Reporting - 2. An alleged violation of abuse, neglect, exploitation or mistreatment (including injuries of unknown source and misappropriation of resident property) will be reported immediately, but no later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. 1.Resident #62 was admitted to the facility on [DATE] with diagnoses that included: Chronic Respiratory Failure with Hypoxia, Atrial Fibrillation, Morbid (Severe) Obesity, Type 2 Diabetes Mellitus, Acute Kidney Failure, Anxiety Disorder and Schizophrenia. A review of Resident #62's medical record revealed: A PASRR (Pre-admission Screen/Resident Review) Level II determination letter dated 01/19/24 that justified the resident's nursing home placement in the facility. A significant change minimum data set (MDS) assessment dated [DATE] that documented that the Resident had a Brief Interview for Mental Status (BIMS) of, 11 indicating that the Resident had moderately impaired cognition. In addition, the assessment documented that the Resident experienced hallucinations, displayed verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) for 1 to 3 days, rejected care daily, was independent with most ADLs (activities of daily living), was occasionally incontinent and received supplemental oxygen. A review of physician's orders dated 02/12/25 that directed: Please document exact behavior exhibited under behavior note. every shift, and Psych Consult and PRN. A Psych Progress Note dated 02/19/25 that documented: 1. Mood and behavior: Upon today's evaluation in my opinion his symptoms of irritability and frustration tolerance are due to underlying anxiety and depression associated with poor self-control declined health, and long hospital stay. The patient is exhibiting episodic flares of depression and anxiety. Denies active passive SI (suicidal ideation). He is future-oriented and wants to get better. A review of a care plan initiated on 02/12/24 that documented: Focus: [Name of Resident # 62]:is dependent on staff etc, for meeting emotional, intellectual, physical, and social needs r/t (if dependent) Physical Limitations; Interventions included: All staff to converse with resident while providing care. A review of a care plan initiated on 02/16/24 that documented: Focus: [Name of Resident # 62] is/has potential to be verbally aggressive r/t (related to) ineffective coping skills; Goal: [Name of Resident # 62] will verbalize understanding of need to control verbally abusive behavior through the review date. Interventions . When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later. A review of a care plan initiated on 02/16/24 that documented: Focus: [Name of Resident # 62] is resistive to care r/t (related to) non adherent to medication and refusal of care; Goal: [Name of Resident # 62] will cooperate with care through next review date; Interventions: . Give clear explanation of all care activities prior to an as they occur during each contact.; Praise the resident when behavior is appropriate. A review of a facility reported incident (DC~13626) dated 04/22/25 that documented: . A review of the facility's investigation packet for the incident revealed the following: written statement by Employee #32/Certified Nurse Aide: The CNA [Employee #28] was passing trays, [Resident #62's Room #] came to the door. The CNA said, 'Oh you scared me. The resident said, I didn't do anything. The CNA said you crazy you talk to yourself. The resident said, yes, that's why I take medicine.' She [CNA/Employee #28] laughed and the resident said if it's a problem, don't come back to my room. The CNA 's name is [Name of Employee #28]. The resident's name is [Name of Resident #62]. A further review of the facility's investigative documents showed no documented evidence per the facility's policy that Employee#32 reported the alleged incident of verbal abuse immediately to the Administrator, DON, or a nurse or nursing supervisor in her department. Knowledge of the incident came as a result of the facility's ongoing investigation of a separate incident of alleged verbal abuse between Employee #28 and another resident on the unit. During telephone interview on 04/28/25 02:14 PM, Employee #32 stated: I was passing meal trays with the CNA who was training me. Resident #62 was standing at his door, Employee #28 said something like, Oh you scared me, you were talking to yourself. You're crazy. It was my first day and I was just trying to learn and do my job. I had received abuse training during orientation before I was allowed to work on to the unit, but I didn't think to report the incident with Resident #62 until I was questioned about an incident that involved Employee #28 and another resident. After the incident I never saw the CNA on the floor again, and I was told that I should not report to work until I was notified by my supervisor. During a face-to-face interview on 04/28/25 at 9:44 AM, Employee #2 Director of Nursing, she acknowledged the finding and stated that Employee #32 had been given a written and verbal warning for not reporting the alleged incident of staff-to-resident verbal abuse. 2. Resident #40 was admitted to the facility on [DATE] with multiple diagnoses that included: Dementia, Encephalopathy, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Left Non-Dominant Side, Anoxic Brain Damage and Epilepsy. A review of Resident #40's medical record revealed: A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '01,' indicating the resident was severely impaired. Functional abilities that documented the resident required 1+ person assist with bed mobility and 2+ person assist with transfers and toilet use. During a review of Employee #28's (Certified Nursing Assistant, CNA) employment file, it revealed an 'Employee Warning Notice' dated 04/17/25 that documented, Removed from Schedule pending investigation 4/19/25, 4/20/25, 4/22/25 and On 4/17/25, in [room number] the RP (Responsible Party) for Resident #81 alleged that the person that brought her mother's tray called her a [expletive]. Employee #28 was assigned to the resident's room and was responsible for delivering the tray. [The] Employee was suspended pending investigation. A facility reported incident dated 04/22/25 at 6:32 PM documented, During an ongoing abuse investigation on 4/22/25 at about 12:25 PM it was discovered that Employee #29 (CNA) alleged that she witnessed [Employee #28's name] verbally abused [Resident #40's name]. A care plan dated 04/22/25 documented, Focus: A CNA alleged that [Resident #40's name] was verbally abused by another CNA on 04/22/25. Goal: Resident will be safe through the review date. Intervention: Resident will be treated with respect and dignity that he deserves during care. A review of Employee #29's (CNA) employment file showed an 'Employee Warning Notice' dated 04/22/25 that documented, Removed from schedule pending investigation and Violation of Policy/Procedure (Reference Policy HR (human resources) 401) and During the course of an abuse investigation [Employee #29's name] stated that she witnessed the alleged verbal abuse but failed to report it. The investigation is ongoing. During a face-to-face interview conducted on 04/24/25 at approximately 2:41 PM, Employee #3 (Nurse Supervisor) acknowledged the findings and stated, It didn't happen that day (04/22/25). We were investigating an incident with [Resident #81's name]. There was a new CNA, [Employee #29's name], we were just asking the staff about any issues of abuse with residents, and she stated she saw [Resident #40's name] being verbally abused by [Employee #28's name], but she said that it had happened a long time ago. We educated her on reporting right away and she should not wait even if she is a new employee. I don't know how long she has worked here or when she was hired. So that's being investigated to try to figure out when that happened. I don't know when that (verbal abuse) happened. During a telephone interview conducted on 04/25/25 at approximately 10:14 AM, Employee #29 stated, I just started at this job, and [Employee #28's name] was training me. On my last week of two (2) week orientation, I witnessed her talking to [Resident #40's name]. He can be disrespectful, but I don't pay him know mind. He said, 'Get the [expletive] away, leave me the [expletive] alone, leave me alone I'mma (I'm going to) [expletive] you up.' Then [Employee #28's name] said to '[Resident #40's name] if you touch me I'mma (I'm going to) [expletive] you up, I don't have time for this.' Employee #29 further stated that, They (facility staff) have me under her training me and this is what they have me trained under. They came to me with a paper; it was a paper with questions about if I have ever witnessed [Employee #28's name] and I said Yes and that's when I told them what I witnessed. I have talked to [other staff] people in the workspace, and they just say things like 'I don't see nothing, I don't know nothing.' They don't care about the residents here. I was afraid of retaliation if I said anything and the [other staff] people here going against me, it's not confidential. Everybody was watching me, it was so uncomfortable because everyone knew what I [had] reported. During a Face-to-face interview conducted on 04/28/25 at approximately 11:40 AM, Employee #28 stated, There was an incident with the 'B' [expletive] word. I was passing the trays I went to [Resident #81's name] room first. I had worked with her before, and she would use the 'B' word, but I didn't call her that. Employee #28 was asked about her interaction with Resident #40 and she stated, Yes, I've worked with him before. He gets agitated when he's really wet or wants to eat. He has always said the 'B' word to me, but I have never been abusive to him. During a telephone interview conducted on 05/01/25 at approximately 2: 49 PM, Employee #30 (Nurse Educator) acknowledged the findings and stated, If there is a report of abuse allegation, the staff are informed to contact the charge nurse who will reach out to the nurse supervisor immediately. If the allegation is about an employee and the employee is working with the resident, then the employee will be sent home. It's repeated during my education and the facility's [Abuse] policy is also included in the education. What I say to the staff is if a resident reports abuse, even if you believe it's true or not, it must be reported within two (2) hours. The expectation if it's witnessed by another staff, they should tell the charge nurse and nurse supervisor and provide a statement before they leave for the day.

Based on observation, record review and resident and staff interview, the Interdisciplinary Team (IDT) failed ensure a resident was safe to self-administer an Albuterol inhaler for one (1) of 1 sampled resident who self-administer medicine. (Resident #46). The findings included: Resident #46 was admitted on [DATE] with multiple diagnoses including Pulmonary Chronic Obstructive Disease, Bipolar, Schizophrenia, and Anxiety. A policy titled, Self-Administering Medications with a review date of 05/24/24 instructed, Residents have the right to self-administer medications if the interdispilinary team has determined that it is clincally appropiate and safe for the resident to do so . The staff and practitioner will assess each resident's mental and physical abilities to determine whether self-administering medication is clincally appropiate for the resident .the nursing staff will determine who will be responsible (the resident or nursing staff) for document that medications were taken .medications must be stored in a safe and secure place, which is not accessible by other residents . A physician order dated 02/21/25 instructed, Albuterol -Budesonide Inhalation Aerosol 90-80 micrograms/actuation give 2 puffs by mouth every hour hours as need for shortness of breath. A quarterly Minimum Date Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 11 indicating that the resident had a moderately impaired cognitive status. The resident was also coded for requiring supervision from staff with activities of daily living and having a diagnosis of Chronic Obstructive Pulmonary Disease. During an observation on 04/14/25 at approximately 2:30 PM, the resident was observed sitting up in bed watching tv. At the time of the observation, the resident showed the surveyors an Albuterol inhaler that she had in her purse. The employee then stated that she uses her Albuterol inhaler at least 2 times a day (2 puffs) daily for shortness of breath. The resident said, I can take my own medicine like I did at home. I don't want to answer any more questions. A review of the April 2025 Medication Administration Record (MAR) lacked documented evidence that the resident used her Albuterol inhaler from 04/01/15 to 04/14/15. During a face-to-face interview on 04/15/25 at approximately 9AM, Employee #38 (assigned LPN) stated that the resident keeps her Albuterol at the bedside, so she can administer it herself. The employee said that the resident used to complain a lot that she wanted to keep her Albuterol at the bedside like she did when she was home. When asked who documents in the MAR when it is administered, the employee failed to provide an answer. During a face-to-face interview on 04/15/25 at approximately 10 AM, Employee #2 (DON) stated that the resident had not been assessed by the IDT to self-administer medication. The employee said she will ensure the Albuterol is removed from the resident's room.

Based on observations, record review, staff, and resident interviews, for one (1) of 53 sampled residents, facility staff failed to ensure that Resident #266 was free from mental abuse and rough handling/physical abuse by a licensed practical nurse employed by the facility. These failures resulted in psychosocial harm to Resident #266. The findings include: Facility policy entitled Abuse Policy revised 07/2017 stipulates, Definitions .1.Abuse . the willful infliction of injury, unreasoned confinement, intimidation or punishment with resulting physical harm, pain or mental anguish .Includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Treatment/Management .the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect . Resident #266 was initially admitted to the facility on [DATE], with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident #266's medical record revealed physicians' orders documenting the following: -02/25/22 [CONDITION(S)] ([CONDITION(S)]) care q (every) shift for [CONDITION(S)] care; -03/01/22 Patient has Spanish/English communication binder in room. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed that facility staff coded the following: -In section A (Identification Information): A1100 Language .Preferred Language Spanish; -In section C (Cognitive Patterns): Should a brief Interview for Mental Status Conducted? no. -The Brief Interview for Mental Status (BIMS) summary score section was Blank. -In Section G (Functional Status): Bed mobility, Transfer and Toilet use were all coded as Total Dependence requiring Two-person physical assist -Bathing total dependence -Functional Limitation in Range of motion, Upper Extremity No impairment Lower extremity Impairment on both sides -In section J (Health Conditions): Pain Management, Received scheduled pain medication regimen No -In section N (Medications): Medications received Opioid -In section O (Special Treatments, Procedures, and Programs): Respiratory Treatments Oxygen Therapy, Suctioning and [CONDITION(S)] Care. During a face-to-face interview on 03/17/2022 at approximately 3:30 PM Employee #1 informed the survey team that there was an alleged allegation of emotional abuse that involved a staff member and [Resident #266] .the resident's daughter has the video tape of the staff emotionally abusing the resident .this supposedly happened on yesterday (03/16/2022) .we just reviewed the video . A face-to-face interview was conducted on 03/17/22 at approximately 5:00 PM with Resident #266's daughter-in-law who stated that yesterday her mom (Resident #266) told her please take me home there is a lot of mean people. At the time of this interview Resident #266's relatives provided the survey team with a video recording from a private device that they indicated was recorded the previous evening (03/16/22) in Resident #266's room on a private device. A review of the video revealed the following: -Two staff in Resident #266's room were identified as Employee #13 (Licensed Practical Nurse) and Employee #14 (Certified Nurse Aide). -While providing personal care for Resident #266, Employee #13 was observed handling the resident roughly [pulling the resident by the arm and pushing her body to roll her]. The employee was also heard yelling, what did you eat tacos and tequila? .I'm telling you, you crazy f***k Why does she move like that? Does she have worms in her butt? Girl are you part of a human being . The employee continued to taunt the resident by calling the resident's daughter's name multiple times and saying, come and get your mama. -Further observation of the video showed Employee #13 changing the resident's incontinent brief, repositioning resident # 266 in the bed, and suctioning the resident while the resident was lying flat in the bed. -During this time, Resident #266 could be heard speaking Spanish loudly stating the following: .Oh Father help me nobody wants to listen to me .This foot hurts .I have such pain .That's the hand that hurts. Further review of the video showed that Employees #13 and #14 failed to ask Resident #266 if she was in pain while they performed care. During a face-to-face interview on 03/17/22 at 4:34 PM, Employee #13 (LPN) was questioned by the writer regarding the care she provided for Resident #266 on 03/16/22 during the 3-11 PM shift. Employee #13 stated, while we were changing the resident she said, P***a (Spanish expletive). Then I repeated back what she said. I think there is an English barrier, but I think she understands. I said turnover and she understood what I said. Then I said nothing else and the CNA [Certified Nurse Aide] said nothing else. Then the resident tried to take the [CONDITION(S)] out. A general progress note dated 03/17/22 at 10:22 PM documented, Resident is alert, oriented x3 and verbally responsive. [CONDITION(S)] collar intact and suctioned prn with clear moderate sections noted. O2 at 5/L (liters) per min via [CONDITION(S)] tube 28% Fio2 (fraction of inspired oxygen) for respiratory support. Seen by NP [name] on unit and assess the patient. New order given to transfer resident to the [Hospital Name] for further evaluation due to chest pain and knee. No acute distress noted .Resident was transferred to ER (emergency room ) at 5:57 PM . During a face-to-face interview on 03/18/22 at 4:44 PM, Employee #14 (CNA - Agency Staff) was questioned by the writer regarding the care she provided to Resident #266 on 03/16/2022 during the 3-11 PM shift. Employee #14 stated, While I was in the room, she [Resident #266] gets a fear on her face. The charge nurse (Employee #13) likes to work with her CNAs, she does the work. I try to go in rooms by myself .she picks the rooms she wants to do .She does the work; The surveyor asked Employee #14 to explain how she and Employee #13 work together and Employee #14 stated, I just stand waiting for her to turn the resident .This is the same thing that happens all the time. Nothing different. She washes the resident's face very roughly. Employee #13 pulls her (Resident #266) with her arm, we should use the sheet to pull them over. The resident likes to come to the middle of the bed and that upsets [Employee #13]. The lady (Resident #266) started saying P***a so [Employee #13] started calling her a B***h. If the lady (Resident #266) tried to tell her something it made her angry. She yanks them around and she does it to everybody . When asked if she has reported any of her observations or what she shared, she stated, I have not reported this. I'm' not full-time here. I am not fearful of her [Employee #13] . I don't want hostility. None of the other nurses do anything . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During a face-to-face interview on 03/23/22 at approximately 3:03 PM with Employee #2, (Administration Representative) and Employee #15 (Social Worker) Employee #2 stated, Through our investigation, we have bumped up the concern from verbal abuse to physical abuse because of the way [Employee #13] handled the resident.

Based on observation, medical record review and interviews with residents and staff for four (4) of 59 sampled residents, facility staff failed to provide resident with a specialized call system to allow resident to call for assistance if in distress, and/or to make their needs known without waiting for staff to make rounds into the resident's room. Residents' #49, #56, #115 and # 366. Findings include . On August 7, 2019, at 5:00 PM an Immediate Jeopardy (IJ)-J was identified at 42 CFR §483.10(e)(3), F558- Reasonable Accommodations Needs/preferences. On August 17, 2019, at 9:00 AM, the facility's Administrator provided a letter to the State Agency Survey team documenting the corrective action plan which included the following: On 8/5/19 Resident #115 was provided a Breath Call System; on 8/6/19, Resident #49 was positioned to use Breath Call System while in his recliner chair or bed; and on 8/6/19 Resident #366 was given Breath Call System. Nursing Supervisors of the facility were to review all residents to ensure their current call system was appropriate for their use by reviewed all 8/7/19. On 8/8/19 by 3:00 PM an in-service to show the types of call system devices available, location of call system devices and education on how each device works will be done .An assessment tool on types of devices available and how to determine the residents needs/appropriateness will be shared with the staff at the time of the in-service . 8/8/19 and ongoing- all admissions and transfer documents will be reviewed for special communication needs so expected admissions can have the needed call devices available at the time of admission . 8/8/19 by 5:00 PM, each resident will have a communication care plan done at the time of admission and those with needs for special call light devices will have an intervention stating the type of device needed and this intervention will appear daily forcing the staff to sign off the intervention of what device is needed and available to the resident. All current residents will have a care plan reviewed and reported to QAPI (Quality Assurance and Performance Improvement). The residents identified with a newly needed special communication call light device will be reviewed by-weekly at the resident care and safety meeting . The IJ was abated after the team verified that the plan of correction was in place on August 22, 2019 at 5:41 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to a D. 1. On August 5, 2019 at approximately 11:00 AM, Resident #49 was observed in a Geri chair in his room. The surveyor observed that a call bell was clipped to the sheet on the Geri chair. However, Resident #49 was noted to have contractures to both arms and fingers. When asked if he could push the button to call for assistance the resident responded, No; and when asked how he received assistance if he needs it, he said that he has to wait until someone comes to the room. Employee #11 (Charge nurse) was called to the room and asked whether the resident is able to use the call bell. She responded No and added that the call bell was not in use and she was not sure why it was still in the room. At this time, this writer observed a disconnected touch pad on the floor near the head of the resident's bed and pointed to it. The employee stated, That's not the one. It's the other one over there and pointed to another call system device (Breath Call) which was also disconnected. The employee further stated, I will get the engineer to fix the device right away. The surveyor asked Employee #4 (Unit Manager) to come to the room. Employee #4 and Employee #11 both acknowledged that they failed to provide the resident with a call device that he could use to call for assistance when needed. A follow up visit was made to the room on 8/5/19 at approximately 3:00 PM. The resident was observed resting comfortably in bed. The Breath Call was correctly positioned and the resident demonstrated being able to use the machine. During a face-to-face interview on 8/5/19 at 12:00 PM, Employee #5 acknowledged the findings. 2. Observation of Resident #56's room on 08/07/19 at 10:15 AM, showed the resident lying in bed in supine position noted to have physical limitations and a [CONDITION(S)] with oxygen being delivered at 5 liters per minute by way of a tracheal mask was in place. The resident was also noted to have a specialized call system near his face that he could not reach to access. When the resident was asked by the surveyor to demonstrate how he used the specialized call system, the resident raised his head to reach the mouth piece of the call system, but he was unsuccessful. Resident #56 then stated, I breathe into it to call the nurse. I can't reach it right now, but I'm ok because I don't need anything. During a face-to-face interview at the resident's bedside on 08/07/19 at 10:20 AM, the Unit Manager, stated that when staff provides care for the resident, they forget to put the call system within reach for the resident. The Unit Manager then placed the call light within reach for the resident, and the resident was then able to demonstrate how he uses the call light to alert staff when he needs assistance. Review of Resident #56's current medical record showed that the resident had multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Continued review of the resident's current medical record revealed an annual Minimum Data Set (MDS) dated [DATE] that documented under Section G0110 (Functional Status- Activities of Daily Living)- the resident was coded as a 4, which indicated that Resident #56 is totally dependent on staff for all activities of daily living. Further review of the previously mentioned MDS also revealed that under Section G0400 (Functional Status- Limitation of Range of Motion) the resident was coded as a 2, which indicated that the resident had impairment of both upper and lower extremities. A second observation on 08/08/19 at 10:40 AM showed Resident #56 lying in bed in the supine position with a specialized call system near his face. The resident, however, was unable to access the call system at the time of this observation. When the resident was asked if he could use the call light, he stated, I can't reach it. Resident #56 also said that when the facility changed his bed about a year ago, the call light no longer fit on the side rail of his bed. During a face-to-face interview at Resident #56's bedside on 08/08/19 at 10:50 AM, the Unit Manager/Employee #5 stated, The call light falls out of place sometimes, so we need to put some paper towels under it to keep it in place. Another observation on the same day (8/8/19) at 11:00 AM showed Resident # 56's call light was attached to the bed rail (left side) with multiple paper towels wedged beneath it. At the time of this observation, the resident was able to access the specialized call system. During a face-to-face interview on 8/8/19 at 11:30 AM, Employee ##5 acknowledged the findings. 3. Resident #115 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 10 to indicate moderately impaired cognition. Section G [Functional Status] resident is coded as 4 total dependence on staff for dressing, personal hygiene (combing hair, brushing teeth, shaving). G0400 [Functional Limitation in Range of Motion] resident is coded as 1 to indicate upper extremity (impairment on one side) and coded as 2 to indicate impairment on both sides for lower extremities. Observation on 8/5/19 at 11:00 AM showed resident lying in bed and unable to use the call light. The resident was asked can you use the call light. The resident's daughter (present in the room) responded the call bell is in the box on top of the cooling system, it is not able to fit on the wall, they tried but it doesn't fit. The resident then stated, I can't use the call light and they know this, my daughter has to get someone, or I just have to wait until someone comes in the room. Writer observed a specialized call system in a box labeled Breath Call model [X-XXX] placed on top of the HVAC (heating, ventilation, and air conditioning) system in the resident's room. During an interview on 8/6/19 at approximately 11:00 AM Employee # 3 was asked to tell me about Resident's call light, Employee #3 responded, We know that she is not able to use the call light so we have an hourly monitoring system in place, here are the monitoring sheets, staff check her hourly. Review of the resident's care plan initiated on 7/16/19, failed to include the resident's method of communication. Review of document titled 1 Hour Monitoring Tool showed staff did not consistently record monitoring the resident, staff was unable to provide evidence of monitoring sheets for the following dates: 7/15-7/19/19 7/27-7/29/19 7/31-8/7/19 During an interview on 8/6/19 at approximately 11:30 AM, Employee # 9 stated, We ran out of the monitoring sheets so we do not have any sheets to give you. Employee #3 (Unit Manager -present during the interview) was unable to verify and or confirm that staff were monitoring the resident hourly. Review of the medical record showed no harm to the resident. Facility staff failed to provide resident with a specialized call system to allow the resident to call if in distress, or to make their needs known without waiting for staff to make rounds in to the resident's room. During a face-to-face interview on 8/6/19 at approximately 11:30 AM, Employee #3 acknowledged the finding. 4. Resident #366 was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Comprehensive Minimum Data Set (MDS) dated [DATE] showed a Brief Interview for Mental Status (BIMS) score of 14 to indicate cognition intact. Section G [Functional Status] resident is coded as 4 total dependence on staff for dressing, personal hygiene (combing hair, brushing teeth, shaving,). G0400 [Functional Limitation in Range of Motion] resident is coded as 2 for upper and lower extremity which indicates impairment on both sides. During an interview on 8/6/19 at approximately 3:00 PM, the surveyor asked Resident #366 where is your call bell? The Resident responded, I don't have a call bell. Resident was asked: How do you call for assistance? Resident then began to make a clicking sound with his mouth and stated, If they can hear me making the sound then they come into the room otherwise I have to wait until someone comes into the room. Observation of the room did not show a call bell system in place. The resident's mother was also present in the room and stated, Since coming back to a new room from the hospital (on 7/29/19) he has not had a call light. Employee #3, Unit Manager, was called to the room and her immediate response was Where is your call light (speaking to the resident), the resident stated, I don't' have one [Breath Call] since I came back [to the facility] in this new room, they never hooked it up [Breath Call] it must be in my old room. Observation on 8/6/19 at 3:00 PM failed to show a call system in place for the resident to use to call if in distress and or to make his needs known to staff. Review of the medical record showed no harm to the resident. Facility staff failed to provide Residents' #49, #56, #115 and # 366 with specialized call systems to allow residents to call for assistance if in distress, and/or to make their needs known without waiting for staff to make rounds into the resident's room. During a face-to-face interview on 8/6/19 at 3:00 PM, Employee #3 acknowledged the findings.

Based on observations, record reviews family and staff interviews for two (2) of 59 sampled residents facility's staff failed to follow-up on injuries of unknown origin with the potential for abuse or neglect by failing to: (1) investigate a bruise to the left eye of Resident #58 who was totally dependent on staff for all activities of daily living; and (2) thoroughly investigate fractures sustained to the sacral and pubic areas of Resident #80 (who is Hispanic and English is her second language). Findings included . On August 14, 2019, at 6:25 PM an Immediate Jeopardy (IJ)-K was identified at 42 CFR §483.12 F600, Freedom from Abuse, Neglect, and Exploitation. On August 15, 2019, at 1:00 PM, the facility's Administrator provided a letter to the State Agency's Survey team documenting the corrective action plan which included the following: Resident #58 - On 8/14/19 Resident #58 was given an x-ray of the left orbit where the bruise was located, and on her left hand where the second bruise was noted and on her left knee where scrape was noted. X-ray of left hand and left knee are both negative. However, the x-ray of the left orbit shows a possible fracture that must be confirmed by CT-scan [computerized tomography] due to poor visualization of the orbit by x-ray. The resident will be sent toER on [DATE] to accomplish the CT expeditiously. 8/15/19 - Residents on the fourth floor where [Resident #58] is located will be interviewed to determine if there are any other falls previously unreported or any new pain via pain assessment. Resident #80- 8/14/19- X-ray result received on 6/24/19 showed unremarkable for the left hip. However, a subsequent MRI [magnetic resonance imaging] done on 8/2/19 showed two displaced and two non-displaced fractures. An Orthopedic appointment was held on 8/09/19 with recommendations from the orthopedic doctor to continue physical therapy and all previous orders were continued for Rehab. On 8/13/19 Rounds and interview conducted by Social Worker on all residents on the fourth floor with no indications or concerns of mistreatment. 8/13/19 Rounds conducted by RCC [Resident Care Coordinator] and assigned CNA [Certified Nurse Aid] to verify no other residents are affected by the deficient practice. 8/15/19 and ongoing In-service will be provided to licensed staff on assessments to include injuries of unknown origin. All clinical staff will be educated on proper pathways of communication methods to facilitate proper assessments and follow up to non-English speaking residents as they receive information from families, visitors and other disciplines. 8/15/19 and ongoing- All staff will be in-serviced on language line use whether or not the family is present for interpretation. All staff will be in-serviced on the BridgePoint Abuse and Neglect Prevention Policy to include injury and or abuses of unknown origin. All licensed staff will be in-serviced on situations requiring incident reports and DOH [Department of Health] notifications. Managers and supervisors will be in-serviced on appropriate rounding methods. 8/15/19 Daily rounding will occur by one of the above-named department heads based on the created schedules, every day on the fourth floor with results matched with the 24-hour reconciliation report. This data will be shared with the Administrator and the DON [Director of Nursing]. 8/19/19 and ongoing- Clinical and non-clinical staff who enter a resident's room will be in-serviced on the two forms of communication when they notice injury or other change in condition or comfort by: a) Verbalizing to a nurse on a same shift and providing a written note (similar to a stop and watch program). The IJ was abated after the team verified that the plan of correction was in place on August 22, 2019 at 5:40 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to an H. 1.Facility staff failed to follow-up on injuries of unknown origin with the potential for abuse or neglect by failing to investigate a bruise to the left eye of Resident #58 who was totally dependent on staff for all activities of daily living. Definition: Bruise (per Taber's Dictionary): A traumatic injury (usually to the skin but sometimes to internal organs) in which blood vessels are broken but tissue surfaces remain intact. Discoloration, swelling, inflammation, and pain are typical signs and symptoms. Fresh bruises on the skin are often red or purple. Older bruises may turn green and then yellow or brown, as the blood products within them age and are reabsorbed, but gauging the age of a bruise by its color is imprecise, at best. Bruising in infants may suggest occult child abuse. Bruising in older adults is more often an indication of the use of anticoagulant drugs than of physical mistreatment. https://www.tabers.com/tabersonline/view/Tabers-Dictionary/ 3/all/bruise Observation of Resident #58's room on 08/13/19 at 9:28 AM showed the resident lying in bed on her right side with a purple-yellowish bruise under her left eye. Continued observation revealed that the resident had limited physical ability, and was [CONDITION(S)] dependent with oxygen being delivered at 5 liters per minute by way of a tracheal mask. During a face-to-face interview on 08/13/19 at 9:30 AM, Employee #19 (RN), who was assigned to the resident, stated that when she conducted rounds at the beginning of her shift, she observed the resident with a bruise under her left eye. Employee #19, said that she did not know when the resident acquired the bruise, nor did she ask the off-going nurse about it. Additionally, Employee #19, RN, stated, I haven't worked on this floor in two months. I was floated to this floor today. Employee #19, RN, regularly works on another unit. On 08/13/19 at 9:40 AM, during an interview, Employee #22 (CNA) assigned to the resident stated, I saw the bruise under the resident's left eye last Thursday [08/08/19], and I told the nurse (Employee #22- RN). On 08/13/19 at approximately 9:45 AM, the surveyors Called the Administrator, Unit Manager (Employee #5), and Director of Nursing, to Resident # 58's room to observe the bruise under the resident's left eye. During a face-to-face interview at the resident's bedside, they all stated that before this observation, they were not aware of the bruise under Resident # 58's left eye. Continued interview revealed they would start an investigation. During a face-to-face interview on 08/13/19 at 2:25 PM, the Administrator, stated, While during our investigation, we pulled her (Resident # 58) up in bed, and noticed the way she's positioned [her body] hits the side rail where her bruises were. The Administrator then said that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nursing notes dated from 01/02/19 through 08/13/19 showed there was no documented evidence that Resident #58 had [CONDITION(S)] activity during that period. Additionally, a review of the Plan of Care initiated on 12/08/18 lacked documented evidence of how the staff was to manage or monitor Resident #58 for [CONDITION(S)] activity. On 08/13/19 at 3:05 PM, during an interview, Employee #23, CNA, stated that she provided care for Resident #58 during the evening shift on 08/08/19. When asked, while working with the resident on 08/08/19, did she notice anything different with the resident, she stated, Yes, she had a bruise under her left eye, and I called the charge nurse (Employee #21- LPN) into the room to see the resident. After the LPN left the room, I continued providing care. During a face-to-face interview on 08/13/19 at 4:40 PM, Employee #21 (LPN), stated that she had worked with Resident #58 on 08/08/19 during the evening shift. Employee #21, LPN, also said, I did not notice a bruise under the resident's eye. When asked, if Employee #23, CNA, made her aware about anything different with the resident, Employee #21, LPN, stated, No, she did not. During a face-to-face interview on 08/14/19 at 11:26 AM, RN #2 stated, I worked with the resident last week, and I did not see anything different with the resident. When asked, if anyone made her aware of a bruise under Resident #58's left eye, she stated, No, they did not. Review of the staffing sheets revealed Employee #20, RN, worked with Resident #58 during the day shift on 08/05, 08/06, 08/08, 08/09 and 08/10/19. On 08/14/19 at 1:15 PM, during an interview, Employee #24, CNA, stated, When I worked last week (dayshift-08/10/19), I saw a bruise under the resident's left eye, and I told the nurse (Employee #20, RN). On 08/14/19 at 1:30 PM, during an interview, the Respiratory Therapist stated, I worked with the resident (Resident #58) last week (08/06/19), and I didn't notice anything different with her. Review of Resident #58's current medical record on 08/13/19, starting at 12:00 PM showed a physician' assessment dated [DATE] at 11:00 AM. The physician documented that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician also documented, [Resident's name] noted to have contusion below the left eye and dorsal aspect [of] left hand. Further review of the record revealed a Skin & Wound evaluation dated 08/13/14 at 11:04 AM that showed the following wound assessments: 1. Left eye- purplish-gray discoloration under-eye discoloration appears to be dissipating with the following measurements: area 5.3 centimeters, length 3.7 centimeters, and width 2.0 centimeters. The injury was acquired in-house on the exact date of 08/13/19. 2.Left knee- dry abrasion with reddish color with the following measurements: area 1.2 centimeters, length 1.5 centimeters, and width 1.1 centimeters. The injury was acquired in-house on the exact date of 08/13/19. 3.Left hand- purple discoloration on the dorsum aspect with the following measurements: area 1.9 centimeters, length 2.0 centimeters, and width 1.3 centimeters. The injury was acquired in-house on the exact date of 08/13/19. Continued review of the resident's current medical record revealed nursing notes dated from 08/01/19 to 08/12/19 that lacked documented evidence that Resident #58 had a bruise below her left eye, a left knee abrasion, or a bruise on the dorsal aspect her left hand. Further review of the medical record revealed medication administration records that failed to show evidence that the resident had been assessed or medicated for pain from 08/01/19 to 08/12/19. The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of certified nursing assistants Task Sheets dated from 08/01/19 to 08/12/19 revealed that the certified nursing assistants were to monitor Resident# 58's skin and documented any changes every shift. The task sheets, however, lacked documented evidence of changes to the resident's skin to include left eye bruise, left knee abrasion or left-hand bruise. Review of the Respiratory Therapist's note dated 08/06/19 lacked documented evidence Resident #58 had skin injuries to include left eye bruise, left knee abrasion, or left-hand bruise. Review of the Nursing Reconciliation Reports/24 Hour Report (used to monitor all issues or concerns with residents) for the dates of 08/01/19, 08/05/19, 08/06/19, 08/07/19, 08/08/19, 08/09/19, and 08/12/19 lacked document evidence of Resident #58's left eye bruise, left knee abrasion or left-hand bruise. Review of the Care Plan with a revision date of 03/02/17 documented, [resident's name] requires skin inspection every 2 [hours] observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse. The resident's current clinical medical record and certified nursing assistant's task sheets (from 08/01/19 to 08/12/19) lacked documented evidence that the resident's skin was assessed every two hours. The annual Minimum Data Set, dated dated dated [DATE] showed in section G (Functional Status) the resident was coded as total dependence and required two (2) person assist with bed mobility. During interviews with Employees #22, #23, #24 (certified nursing assistants), however, they all stated that they provided bed mobility (turning and repositioning) for Resident #58 without the assistance of a second person. Review of an Orbital X-ray dated 08/14/19 documented the following conclusion, Radiographic suggestion of acute minimally displaced fracture at the left orbital medial wall. This can be further evaluated with CT (computed tomography) examination of the facial bones. Review of Computed Tomography Scan (Axial scans through the brain and facial bones without contrast) dated 08/15/19 revealed the following impression: No acute intracranial process. Extensive encephalomalacia in the bilateral cerebral and cerebellar hemispheres is new since prior exam. Depressed left nasal bone fracture. Old right orbital floor fracture. Facility's staff failed to follow-up on injuries of unknown origin as the potential for abuse or neglect for Resident #58 who was totally dependent on staff for all activities of daily living. During a face-to-face interview with Employees' #1, #2 and #5, on August 14, 2019 at 6:25 PM, they acknowledged the findings. 2. Facility's staff failed to follow-up on injuries of unknown origin with the potential for abuse or neglect by failing to thoroughly investigate fractures sustained to the sacral and pubic areas of Resident #80 (who is Hispanic and English is her second language). According to the Minimum Data Set (MDS) the Resident lacks capacity to make decisions (Secondary to the removal of a brain tumor) and needs extensive assistance from staff for all activities of daily living. During a telephone call with Resident #80's family member on 8/12/19 at 1:45 PM she stated, While visiting my mother on 6/22/19 at around 11:00 - 11:30 AM, she complained of pain to the left hip and told her, she had fallen. I informed the charge nurse of the fall on 6/22/19. (I don't recall her name). The charge nurse stated that no one had reported a fall. On 6/23/19 I told RN #10 [assigned to the resident] my mother fell and showed her the bruise. On 6/24 I spoke with RN #10 again and requested an X-ray because my mother continued to complain of pain and did not want to go to therapy. I also spoke with the physician and he said he would do the X-ray. The X-ray was done and it was negative but my mother still had pain. According to a Physical Therapist's progress note dated 6/24/19, Resident #80 had a bruise to the left elbow. According to the incident report dated 6/27/19, the resident had an alleged fall on 6/22/19 . the facility was informed by the resident's daughter during a care plan meeting on 6/27/19. Review of the X-ray report of Resident #80's left hip joint dated 6/24/19 revealed an unremarkable examination of the left hip joint. Review of the Nursing notes dated 6/22 through 8/2/19 showed Resident #80 complained of pain and was medicated for left hip and leg pain on nine (9) occasions. Review of the facility's incident report dated 8/7/19 showed, on 6/27/19, the facility reported the incident to DOH [Department of Health] on [6/22/19]. Due to complaints of pain an X-ray was done which was negative. Further report of pain prompted an MRI that shows two non-displaced fractures and two displaced fractures. Resident #80 received an MRI of left hip on 8/2/19 (six weeks after the initial complaint). The MRI showed the following injuries. 1. Acute fracture of the left sacral ala. 2. Acute non-displaced fracture of the anterior column of left acetabulum. Intact femur. 3. Acute non-displaced fracture of the left pubic bone. 4. Acute displaced fracture of the left inferior pubic ramus. During a face-to-face interview with the Employee #5 (unit manager) she stated that she became aware of the fall during the care planning meeting on 6/27/19. Through interview with the charge nurse assigned to the resident on 6/23/19 she denied any knowledge of the fall or the bruise. However, through interview with the physical therapist on 8/12/19, she confirmed that she saw the bruise on the Resident's left elbow on 6/24/19. There is no evidence that the facility staff thoroughly investigated the family member's concern regarding her mother stating that she fell and failed to investigate how the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident continued to complain of pain, subsequently an MRI was done and revealed that Resident #80 had multiple fractures (acute fracture of the left sacral ala, acute nondisplaced fracture of the anterior column of the left acetabulum, acute nondisplaced fracture of the left pubic bone and acute displaced fracture of the left inferior pubic ramus). Facility's staff failed to follow-up on injuries of unknown origin with the potential for abuse or neglect by failing to thoroughly investigate fractures sustained to the sacral and pubic areas of Resident #80 (who is Hispanic and English is her second language). During a face-to-face interview with Employees' #1, #2 and #5, on August 14, 2019 at 6:25 PM, they acknowledged the findings.

Based on observation, staff and resident interviews for one (1) of 10 residents reviewed, it was determined that facility staff failed to identify Resident #1's venous ulcer on the right bunion area prior to the development of eschar. The findings include: Resident #1 was admitted to the facility on May, (YEAR). According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 2, (YEAR), Resident #1 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]. Resident #1 had a tracheotomy and a gastric feeding tube. Resident #1 was hospitalized for [REDACTED]. The following nurses' notes were reviewed: May 8, (YEAR) at 14:26 (2:26 PM): No clinical changes noted in this shift. Resident is alert and responsive to tactile stimuli and verbal cues. Vent dependent, AC mode for respiratory support.[MEDICAL CONDITION] and suction provided. Breathing is even and unlabored, lung sounds clear to auscultation. Positive bowel sounds x 4 quadrants, abdomen is soft and non-distended. ADLs provided as needed, HOB is elevated. T&P every 2 hours for comfort. All due meds given via [DEVICE], no diabetic reaction noted. Safety precaution maintained. Will Monitor. May 9, (YEAR) at 8:18 AM: Resident noted with right great toe Deep Tissue Injury (DTI). Resident alert with history and [MEDICAL CONDITION]. Type II diabetes,[MEDICAL CONDITIONS]. Upon assessment, site remains dry and pale. No drainage noted. Site clean with normal saline, Skin prep applied and site left open to air. Wound nurse at bedside who evaluated resident. RP could not be reach at this time. NP to evaluate while in the building. Incoming nurse notified to follow-up with NP/Wound nurse for possible Doppler study of the right toe. According to a Doppler completed (MONTH) 10, (YEAR), ABI completed (MONTH) 9, (YEAR): Left ABI > 1.4, Right 0.51 According to www.nih.gov: The Ankle Brachial Pressure Index (ABPI) test is widely used in the setting of [MEDICAL CONDITION] by a diverse range of practitioners. A low ABI is associated with a greater incidence of severe disability in walking 1.0 - 1.2 - normal range 0.90 - 0.99 - acceptable 0.80 - 0.89 - some arterial disease 0.5-0.79 - moderate arterial disease Under 0.50 - severe arterial disease According to www.nih.gov: A deep tissue injury is a unique form of pressure ulcer. The National Pressure Ulcer Advisory Panel defines a deep tissue injury as A pressure-related injury to subcutaneous tissues under intact skin. Initially, these [MEDICAL CONDITION] have the appearance of a deep bruise. These [MEDICAL CONDITION] may herald the subsequent development of a Stage III-IV pressure ulcer even with optimal treatment. (National Pressure Ulcer Advisory Panel (NPUAP), 2005). You should be alert to the development of deep tissue injuries. Here's how NPUAP describes these ulcers: localized area of maroon or purplish discoloration of intact skin OR a blood-filled blister that forms due to shear and/or pressure prior to the identification of the discolored area, the skin may feel boggy, firm, mushy, painful, cooler or warmer than the surrounding skin the wound may progress to a thin blister overlaying a dark wound bed, which may eventually be covered by eschar additional tissue layers may become rapidly exposed even with optimal treatment You should be alert to the development of deep tissue injuries. Here's how NPUAP describes: There is evidence that demonstrates the layers of the skin are more resilient to pressure than muscle tissue, so many pressure ulcers start in the muscle. Pressure ulcers can present within 24 hours of insult or can take as long as 5 days to appear. When there has been damage to the muscle tissue it may take days before there is any indication of a pressure ulcer on the surface of the skin. There was no evidence in Resident #1's record that facility staff noted a dark purple discoloration or blister on the resident's right bunion area. According to a physician's admission order initially dated (MONTH) 10, (YEAR) and reviewed with each 60 day orders, directed the following: Skin assessment twice weekly every night shift every Mon, Thur. May 3, (YEAR) - not initialed as completed May 7, (YEAR) - not initialed as completed May 17, (YEAR)- not initialed as completed May 21, (YEAR) - not initialed as completed May 24, (YEAR) - not initialed as completed May 28, (YEAR) - not initialed as completed May 31, (YEAR) - not initialed as completed The nurses' notes were reviewed for (MONTH) (YEAR). There was no evidence that the skin assessments were completed for the above cited dates. In the presence of Employee #1, on (MONTH) 15, (YEAR) between 9:30 AM and 10:30 AM, 10 residents' feet were inspected. There were no skin issues identified. A face-to-face interview was conducted with Employees #1 and #2 on (MONTH) 15, (YEAR) at 9:00 AM. Both employees acknowledged that they had missed the development of the eschar on Resident #1's right bunion. The record was reviewed (MONTH) 15, (YEAR).

Based on observation, record review, and staff interviews for one (1) of 36 stage 2 sampled residents, it was determined that facility staff failed to adequately assess Resident #32 ' s tracheal site to ensure that necessary treatment and services were provided. Subsequently, the resident developed unstageable pressure ulcer(s) in the tissues surrounding the trachea (peritracheal region) that were initially assessed at advanced stages. Resident #32 The findings include: Policy: [MEDICAL CONDITION] Care, Policy Number: CP.507 effective date December 2014, Revision/Review Date: 2/2016 Stipulated, Policy: A. [MEDICAL CONDITION] care will be provided to [MEDICAL CONDITION], neck, and stoma site B.I.D. (twice daily) and PRN (as needed) (for excessive discharge and/or grossly soiled drain sponges), or as ordered by physician .Procedure: B. [MEDICAL CONDITION] Care: .13. Examine neck and stoma for any breaks in skin integrity. Clinically competent staff member documents in appropriate area of patient ' s medical record. Documentation should include .4. Notification of any changes to patient ' s nurse and attending physician and/or Pulmonologist . According to the Comprehensive Physical Assessment completed and signed by the registered nurse on April 22, 2016, Resident #32 was [AGE] years old, ventilator dependent and had [DIAGNOSES REDACTED]. The History and Physical form signed and dated by the physician on April 23, 2016 revealed that Resident #32 ' s [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) dated [DATE] revealed: In Section C (Cognitive Patterns) the resident was coded as severely impaired. In Section G0110 (Functional Status) the resident was coded as totally dependent, requiring assistance of one or two people for bed mobility, dressing, eating, toilet use, and personal hygiene. In Section G0400 (Functional Limitation and Range of Motion) the resident was coded as being impaired on both sides (upper and lower) extremities. In Section I (Active Diagnoses) the resident was coded as having [MEDICAL CONDITIONS]([MEDICAL CONDITION]), Ventilator, [MEDICAL CONDITION] and Hypertension. Under Section M 0150 the resident was coded as being at risk for developing pressure ulcers. In Section M 0210 (Current Number of Unhealed Pressure Ulcers) the resident was coded as 0 indicating that the resident was admitted without pressure ulcers. The Pressure/stasis ulcers/skin conditions care plan initiated on April 22, 2016 revealed Interventions: assess skin integrity at least Q (every) shift, massage around boney prominences, turn and reposition Q (2) two hours, pressure relief mattress or specialty, skin assessments as on admission, readmission. Quarterly .and as needed. A physician ' s telephone order dated May 6, 2016 (no time noted) directed: Cleanse [MEDICAL CONDITION] site wound with nss (normal saline solution) pat dry and apply Skin Prep (Skin prep - a liquid film-forming dressing that forms a protective film to protect skinhttp://www.woundsource.com/product/skin-prep-protective-dressing) q (every) shift until seen by wound team .Wound consult on 5/9/16. The clinical record lacked evidence of a comprehensive assessment of the resident ' s tracheal site wound to correlate with the physician ' s telephone wound treatment order of May 6, 2016. The nurse ' s notes and physician notes lacked evidence of identification, characteristics (such as the stage, thickness, size etc.) and/or an assessment of an alteration in the skin integrity at the tracheal site to warrant obtaining an order for [REDACTED].>According to a physician ' s progress note dated May 7, 2016: Peritracheal Ulcer .Post-surgical tracheal wound expanded due to pressure now unstageable . A nurse ' s entry dated May 7, 2016 at 12 PM read: .wound treatment [MEDICAL CONDITION] done. Right wound noted with 100% granulation tissue ø (no) drainage noted .appeared dark . A nurse ' s entry recorded May 7, 2016 at 11:30 AM, SBAR (Situation Background Assessment Recommendation)/ Acute Change in condition report .two open areas noted [MEDICAL CONDITION] . An entry documented by the physician consultant on May 7, 2016 (no time entered) read as follows: Wound Care Physician Assessment . Etiology- post surgical; Side/Arrangement: peritracheal: duration (less than symbol) 10 days size 0.2 x 1.5 x 0.1cm; Drainage Serosanguinous; 50% granulation. A physician's order [REDACTED]. According to the Wound and Skin Care Progress Note dated May 8, 2016, Location Neck-[MEDICAL CONDITION].Characteristics etiology/ unstageable r/t(related to) medical device . A physician's order [REDACTED]. A review of the Respiratory Therapist Notes and the Nursing Progress Notes from April 22 through from May 6, 2016 revealed that tracheal care was completed at minimum twice a day. According to a nurse ' s note dated May 9, 2016 at 2:30 PM: Seen by wound nurse [MEDICAL CONDITION] wound which measures 2x3 and necrotic .wound is device induced pressure ulcer .new order to clean with wound cleaner and apply Xeroform gauze q daily. According to the Wound Care Physician assessment form dated May 14, 2016 Duration (less than symbol)10 days ' size 0.2 x 1.5 x 0.1cm 100 % necrosis. According to the Wound and Skin Care Progress Note dated May16, 2016, Wound #1 Neck-[MEDICAL CONDITION]: Characteristics etiology/ unstageable r/t (related to) medical device .2 x 3 cm .treatment: Xeroform gauze dressing daily as per order. Wound #2 location: Lt (left) side of [MEDICAL CONDITION]. Characteristics etiology/ unstageable r/t medical device. Black dry eschar .1x1.5 cm .treatment keep open to air. According to the National Pressure Ulcer Advisory Panel, Pressure Ulcers in Adults: Predication and Prevention, page 2, When eschar is present, accurate staging of the pressure ulcer is not possible until the eschar has sloughed or the wound has been debrided. Resident #32 was observed on June 14, 2016 at 10:00 AM lying in bed on his/her back with his/her head flexed forward, chin resting on the right shoulder, with a dressing observed in the peritracheal area [MEDICAL CONDITION] in place. Resident #32 ' s plan of care included assessment(s) by rehabilitation services as directed by the physician ' s admitting orders dated April 22, 2016, Rehabilitation (rehab) Screen for PT (physical therapy) OT (occupational therapy), Speech therapy . An Occupational Therapy Screen was conducted on April 25, 2016 and revealed, Pt (patient) is not currently a rehab candidate. Pt is dependent in a vegetative state and presents with no contractures .Discharge to SNF (Skilled Nursing Facility) unit on restorative program. According to the April and May 2016 Restorative Flow Sheets the resident received Passive Range of Motion exercises for bilateral upper extremities and bilateral lower extremities. A face-to-face interview was conducted on June 17, 2016 at approximately 11:30 AM with Employee # 24. When queried he/she stated the resident flexes his/her head to the right with her /his chin pointed down and this caused the pressure on [MEDICAL CONDITION] which caused the development of the pressure ulcer. He/she further stated [MEDICAL CONDITION] is routinely done by the respiratory therapists. The employee acknowledged that there was no pressure relieving device or interventions implemented to reposition the resident ' s head/neck away from [MEDICAL CONDITION] after the pressure ulcers were detected. A face-to-face interview was conducted on June 17, 2016 at approximately 11:45 AM with Employee #21. When queried he/she stated respiratory does remove the inner cannula (of the trach) daily and replace it. He/she acknowledged that the resident flexes his/her head forward and placed pressure on [MEDICAL CONDITION]. This placed him/her at risk for this type of breakdown and resident ' s skin is inspected daily [MEDICAL CONDITION]. A face-to-face interview was conducted on June 20, 2016 at approximately 10:30 AM with Employee #18. He/she acknowledged that the resident was admitted without pressure sores to [MEDICAL CONDITION], and subsequently developed a two (2) unstageable areas below (underneath) [MEDICAL CONDITION] of pressure [MEDICAL CONDITION] was detected as unstageable before treatment was started. He/she was informed (of the pressure ulcer) by the respiratory therapist. He/she further acknowledged that no pressure relieving device(s) was implemented after the pressure ulcers developed. A face-to-face interview was conducted on June 22, 2016 at approximately 11:00 AM. Employee #19 was queried if the resident currently had one or more pressure ulcers? He/she responded, Yes, [MEDICAL CONDITION] has an unstageable pressure ulcer from [MEDICAL CONDITION] against his/her skin. Respiratory therapists and registered nurses recorded/documented that tracheal care was done a minimum of twice daily from April 22 through June 6, 2016, however, there was no evidence that the facility staff assessed an alteration in the integrity of the resident ' s skin at the peritracheal region prior to the development and detection of unstageable pressure ulcers on May 6, 2016. The clinical record lacked evidence that a comprehensive assessment of the peritracheal wound(s) was conducted on May 6, 2016, the date physician treatment orders were obtained. A review of the Medication Administration Record [REDACTED]. Lastly, once the resident was assessed with [REDACTED]. region. A face-to- face interview was conducted with the Employee #5 (Unit Manager) on June 20, 2016 at approximately10:00 AM. After a review of the medical record, Employee #5 acknowledged the aforementioned findings. The medical record was reviewed on June 20, 2016.

Based on observation, clinical record review, review of employee personnel files and staff interviews, it was determined that the facility failed to ensure that 20 of 20 licensed nurses assigned to provide ventilator services for 12 of 12 ventilator dependent residents were qualified and competent as evidenced by a lack of documentation in personnel records of training, experience and competencies to verify qualifications in ventilator management, and staff failure to identify the way the ventilator delivers a breath to the resident, if the resident initiated breaths on the ventilator, if the ventilator delivered a set breathing rate, and how the ventilator assisted the resident ' s breathing (mechanics of ventilation). Resident #98. Subsequently, Residents #13, 37, 80, 98, 100, 111, 134, 135, 137, 138, and 142 also had the potential to be effected by this deficient practice. The findings include: An Immediate Jeopardy (IJ) was identified at CFR 483.20 Resident Assessment; F282 (Failure to ensure that licensed nurses assigned to provide ventilator services were qualified and competent). The facility's Administrator provided a letter noting a corrective action plan and the IJ was removed on September 25, 2015 at 6:00 PM. Subsequently, the deficiency was identifed at a scope and severity of E. Facility staff failed to ensure that licensed nurses assigned to provide ventilator services were qualified and competent. During the survey period interviews conducted with licensed nursing staff assigned to provide ventilator services to residents revealed a lack of knowledge in the mechanics of ventilation, ventilator function and its correlation to the resident's respiratory status. An example to reflect this determination is delineated in the deficiency documented for Resident #98. Facility Policies: The facility policy dated May 15, 2015, titled ' Ventilator Management and Nursing Care Respiratory Education ' detailed the following information: care of the [MEDICAL CONDITION] .modes of ventilation .alarms and common causes .breath sounds assessment .weaning, and patient suctioning. (This document was provided to the State Agency on September 22, 2015 by the Facility Administrator (Employee #1). The policy entitled, ' Ventilator Settings Definitions ' (no initiated or revised date) included the following information: Mode: The way a breath is delivered, Assist Control: A/C, Synchronized Intermittent Ventilation: SIMV, Continuous Positive Airway Pressure [MEDICAL CONDITION] Rate: (bpm- breath per minute), Usually set at 8-12 breaths per minute, Tidal Volume: The amount of volume inhaled in the lungs. The ventilator delivers a pre-set volume of gas with each breath, Fi02: fraction of inspired oxygen (percent of oxygen a patient is inhaling), and Positive End Expiratory Pressure (PEEP): Special setting on the ventilator that keeps the lungs expanded to help get oxygen from the lungs into the bloodstream. (This policy was provided to the State Agency on September 22, 2015 by the Nurse Educator). ¿ The facility policy #CP.603, last revised June 17, 2015, titled, ' Ventilator Weaning Protocol ' stipulates, II. Policy: Protocol will be applied per physician ' s written order of Wean per protocol. On September 21, 2015 at approximately 9:30 AM, a review of the admission record revealed that Resident #98 was admitted on [DATE] to the facility with a [DIAGNOSES REDACTED]. physician's orders [REDACTED].>¿ A physician's orders [REDACTED]. ¿ A physician's orders [REDACTED]. (Defined by the National Institutes of Health as the gradual withdrawal of ventilatory support through utilization of a variety of ventilator modes, periods of total spontaneous ventilation, and appropriate rest periods for muscle unloading (Respiratory therapy was responsible for initiating weaning). <http://clinicalcenter.nih.gov/ccmd/cctrcs/pdf_docs/Ventilator%20Management/02-Ventilator%20Weaning.pdf> On September 21, 2015 at approximately 9:40 AM an observation of the ventilator settings for Patient #98 was noted as follows: A/C, Rate 12 VT 500 Fi02 40% PEEP 5 On September 21, 2015 at approximately 9:42 AM a review of the 'Ventilator Flow Sheet' completed by respiratory therapy (who adjusted the ventilator settings as per weaning protocol) during the period of September 1, 2015 to September 21, 2015 revealed the following documented ventilator settings: A/C Rate - 12 VT - 500 Fi02 - 40% PEEP - 5 Review of the Nursing Respiratory Flow sheet revealed the following recorded ventilator settings for the period of September 1, 2015 to September 21, 2015: A/C Rate - 10 VT - 500 Fi02 - 30% PEEP - 5 The documented assessment of ventilator settings recorded by the nursing staff on September 21, 2015 failed to correlate with the actual settings that reflected the respiratory status of the resident, as observed. Additionally, from September 1, 2015 to September 21, 2015, the documented assessment of ventilator settings recorded by the nursing staff failed to correlate with the actual settings documented by the respiratory therapist. Interviews: On September 21, 2015 at approximately 9:45 AM, a face-to-face interview was conducted with Employee #16, the registered nurse (RN) who was assigned to care for Resident #98. Employee #16 also confirmed that his/her assignment included the care of Residents #37, 98, 111, 134, 137, 138, who were all ventilator dependent. She was interviewed at the bedside of Resident #98, at the site of the ventilator. He/she was asked to observe Resident #98 and the ventilator, confirm the ventilator settings, describe the mode, the set rate, the resident's rate, and the resident's response to the ventilator. Employee #16 stated the rate was 12; but could not explain his/her documentation of a rate of 10 and Fi02 30% or describe the remaining requested information related to the nursing care for the specialized ventilator services. On September 21, 2015 at approximately 10:30 AM a face-to-face interview was conducted with Employee #42, the licensed practical nurse (LPN) who was assigned to care for residents requiring ventilator services. Employee #42 was asked to observe Resident #98 and the ventilator, confirm ventilator settings, and describe the mode, the set rate, the resident's rate, and the resident 's response to the ventilator. Employee #42 explained the set rate of 12; however, he/she could not further describe the requested information related to the nursing care for the specialized ventilator services. On September 21, 2015 at approximately 10:45 AM a face-to-face interview was conducted with Employee #10, the nurse manager for the unit, regarding the aforementioned findings. He/she acknowledged the findings, stating that the respiratory therapy staff would hold an in-service for the nursing staff. On September 22, 2015 at approximately 9:30 AM a face-to-face interview was conducted with Employee #6, the Staff Development Coordinator, regarding ventilator management training provided to staff and the corresponding documented competencies. He/she stated, I have no knowledge of ventilators, and I made administration aware of that when I took the job. I know the staff spends one day with a Respiratory Therapist. On September 22, 2015 at approximately 10:00 AM a face-to-face interview was conducted with Employee #31, regarding ventilator management training provided to staff and the corresponding documented competencies. He/she stated, The nursing staff shadows a respiratory therapist for one day. I do not have a checklist or competencies for their training. That is the responsibility of the nursing department. Employee Record Review: On September 22, 2015 at approximately 1:00 PM, a review of 20 personnel records of staff, confirmed by Employee #10, who had taken care of residents requiring ventilator services lacked evidence that they were trained and/or had documented demonstration of competency in ventilator management. The following is a list of employee personnel records that were reviewed: Registered Nurses Employee #9 Employee #35 Employee #10 Employee #36 Employee #13 Employee #37 Employee #17 Employee #38 Employee #18 Employee #39 Employee #32 Employee #40 Employee #33 Employee #41 Employee #34 Licensed Practical Nurses Employee #24 Employee #44 Employee #42 Employee #45 Employee #43 A review of the personnel records of licensed nursing staff assigned to provide ventilator services lacked evidence that the staff were adequately trained and/or had documented experience and competence in ventilator care services and airway management. Additional Interviews: ¿ On September 18, 2015 at approximately 3:30 PM, a face-to-face interview was conducted with Employee #4 (Assistant Director of Nursing) regarding the aforementioned findings. He/she was unaware that there was a problem regarding the nurses' knowledge and competence of care and treatment for [REDACTED]. On Tuesday September 22, 2015 at approximately 2:20 PM a face-to-face interview was conducted at approximately 2:28 PM with Employees' #2, #3, and #4. The employees made the following responses related to the quality concerns identified during the survey: ¿ On September 22, 2015 at approximately 2:20 PM Employee #3 stated that he/she was aware that a potential problem could arise, as a result of the knowledge deficit regarding the care and treatment of [REDACTED]. ¿ On Tuesday September 22, 2015 at approximately 2:20 PM , Employees #3 and #4 acknowledged that Employee #6 (Staff Development Coordinator) had a knowledge deficit related to ventilator services and management, and he/she failed to ensure that nursing personnel assigned to care for residents that required the ventilator services received the education and training necessary to ensure proper care and treatment related to specialized ventilator services. In Summary: · Pursuant to the facility's practice and policy (last reviewed and signed by facility administration May 2015) nursing staff is required to demonstrate proficiency in Ventilator Management, Respiratory Care and Specialized services such as, care of the [MEDICAL CONDITION], modes of ventilation, alarms and common causes, breath sounds assessment, weaning, and patient suctioning. ¿ There was no evidence that nursing staff assigned to care for residents who required ventilator services received a comprehensive on-going in-service education/training related to ventilator management; and there was no documented evidence of competencies in the specialized area of ventilator management. ¿ There was no evidence that the Staff Development Coordinator was qualified and experienced in the area of ventilator management. ¿ There was no evidence that each nurse who was assigned to care for residents requiring ventilator services were trained in areas to address the resident's special health care needs.

Based on observations, record review, staff interviews, and resident outcomes, it was determined that the facility failed to provide sufficient nursing staff to ensure the delivery of nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as evidenced by failure to have sufficient staff in both numbers and/or qualifications to meet the needs of 21 of 55 sampled residents. An Immediate Jeopardy (IJ) was identified at a scope and severity of J in the areas of CFR 483.25 Quality of Care, F-309 Failure to ensure that each resident attained/maintained the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care - specifically, Resident #145 and 11 additional ventilator dependent residents that have the potential to be affected by this deficient practice; F-328 Failure to ensure that residents receive the necessary care and treatment relative to ventilator services - specifically, Resident #145 and 11 additional ventilator dependent residents that have the potential to be affected by this deficient practice; a scope and severity of K was identified at F-353 Failure to have sufficient staff in both numbers and/or qualifications to meet the needs of residents, specifically, deficient practices related to the provision of needed care for residents identified in the regulatory groupings of quality of care and quality of life and 483.20 Resident Assessment; F-282 Failure to ensure that licensed nurses assigned to provide ventilator services were qualified and competent - specifically, Residents #98, 145, and 11 additional ventilator dependent residents that have the potential to be affected by this deficient practice. The facility's Administrator provided a letter noting a corrective action plan (see letter attached) and the IJ was removed on September 25, 2015 at 6:00 PM. Subsequently, the Immediate Jeopardy was lowered to a scope and severity of E for each of the tags, F-282, F-309, F-328 and F-353. The findings include: Example(s) of care deficits caused by insufficient quantity and/or quality of nursing staff include: A review of the nurse staffing assignment indicative of the provision of nursing care for residents residing on the 6th floor nursing unit who require special care needs such as ventilator, [MEDICAL CONDITION] and respiratory related services revealed the absence of Registered Nurse (RN) staff during the day-shift (7:00 AM - 3:30 PM) on August 30, 2015. The configuration of the resident population on August 30, 2015 included 12 residents dependent on mechanical ventilators for adequate breathing , 15 residents who had tracheostomies (a surgically created hole through the front of the neck and into the windpipe (trachea) that provides an air passage for breathing), four (4) residents requiring [MEDICAL CONDITION] therapy (Bi-level Positive Airway Pressure - a non-invasive mechanical pressure support ventilation), 2 (two) residents requiring Hi-Flow therapy (High flow nasal cannula oxygen therapy), 55 residents who required nebulization treatments and four (4) residents whose plan of care included ventilator weaning services. The staffing assignment for August 30, 2015 included four (4) Licensed Practical Nurses (LPNs) on duty during the day shift and one (1) respiratory therapist on duty during the period of 7:00 AM - 7:00 PM (12 hour-shift). The absence of Registered Nursing staff on duty (8/30/15 day shift) for the provision of direct care services to residents and/or supervision of LPN practice, would allow residents on the 6th floor nursing unit to be subject to practices inconsistent with State requirements as follows: The scope of practice for LPNs, According to District of Columbia Municipal Regulations for Practical Nursing under Title 17, Chapter 55, Section 5514 The practice of practical nursing means .the performance of actions of preventive health care, health maintenance, and the care of persons who are ill, injured or experiencing alteration in health processes at the direction of the delegating or supervisory registered nurse shall include: (a) Participating in the performance of the ongoing comprehensive nursing assessment process of the client ' s biological, physiological, and behavioral health, including the client ' s reaction to an illness, injury, and treatment regimens by collecting data and performing focused nursing assessments; (b) Recording and reporting the findings and results of the ongoing nursing assessment process . In contrast . The scope of practice for RNs According to District of Columbia Municipal Regulations for Registered Nursing under Chapter 54, Section 5414 The practice of registered nursing means the performance of acts requiring substantial specialized knowledge, judgment, and skill based upon principles of the biological, physical, behavioral and social sciences in the following: (a) The observation, comprehensive assessment, evaluation and recording of physiological and behavioral signs and symptoms of health, disease and injury including the performance of examinations and testing and their evaluation for the purpose of identifying the needs of the client and family Additionally, care deficits caused by insufficient quantity and/or quality of nursing staff are delineated in this survey report under the regulatory groupings of Resident Rights, Resident Assessment and Quality of Care and cross referenced as follows: Cross referenced 483.10(b)(11) F157; 483.20(k)(3)(ii) F282; 483.25 F309; 483.25(a)(3)F312; 483.25(c)F314; 483.25(i)F325; 483.25(k) F328 Resident Rights - 483.10(b)(11) F157 Nursing staff failed to notify the physician when two (2) ventilator dependent residents who demonstrated a compromise in respiratory function and two (2) residents experienced a weight loss that exceeded five (5) percent in 30 days. Residents' #145 and #64 and #6, #5. Resident Assessment - 483.20(k)(3)(ii) F282 Facility failed to ensure that 20 of 20 licensed nurses assigned to provide ventilator services for 12 of 12 ventilator dependent residents were qualified and competent as evidenced by a lack of documentation in personnel records of training, experience and competencies to verify qualifications in ventilator management, and staff failure to identify the way the ventilator delivers a breath to the resident, if the resident initiated breaths on the ventilator, if the ventilator delivered a set breathing rate, and how the ventilator assisted the resident ' s breathing (mechanics of ventilation). Resident #98. Subsequently, Residents #13, 37, 80, 98, 100, 111, 134, 135, 137, 138, and 142 also had the potential to be effected by this deficient practice. Quality of Care - 483.25 F309 Nursing staff failed to provide the necessary care and services to ensure residents attain or maintain the highest practicable physical, mental, and/or psychosocial well-being as evidenced by failure to: consistently assess and monitor the status of one (1) who exhibited an acute change in status as manifested by low blood pressure, increased respirations and [MEDICAL CONDITION] to perform an accurate assessment for one (1) resident who experience a documented change in condition; to consistently assess and monitor one (1) resident who was ventilator dependent and experienced [MEDICAL CONDITION] assess and identify the need for one (1) resident who had accumulated white colored substance on his/ her tongue; and failed to ensure that one (1) resident wore protective head gear and that the head circumference was measured in accordance to physician's orders [REDACTED].#145, #37, #5, #104 and #143. Additionally, facility staff failed to conduct comprehensive pain assessments to include characteristics such as intensity, type, pattern of pain, location, frequency and duration of pain for seven (7) residents and consistently assess two (2) residents response to pain intervention. Residents ' #64, #108, #107, #142, #80, #43 and #49. Quality of Care - 483.25(a)(3)F312 Nursing staff failed to ensure one resident received necessary services to maintain good oral hygiene as evidenced by one (1) resident who was observed with an accumulation of white colored substance on his/her tongue. Resident #104. Quality of Care - 483.25(c), F-314 Nursing staff failed consistently provide the necessary services and treatment to manage pressure ulcers as evidenced by failure to perform an accurate assessment to identify the appropriate stage of a sacral ulcer for one (1) resident; and implement measures to promote healing such as bed surfaces, nutritional status and pain management for one (1) resident. Residents #64 and #91 . Quality of Care - 483.25(k), F-328 Nursing staff failed to ensure that residents received the necessary care and treatment relative to ventilator services as evidenced by staff failure to: consistently assess and monitor one (1) ventilator dependent resident who demonstrated symptoms of respiratory dysfunction for greater than 24 hours in the absence of close monitoring, supervision and/or physician notification, subsequently was transferred to ER via 911; consistently assess and monitor one (1) resident who was ventilator dependent and experienced an increase in heart rate and was subsequently sent out 911 (Emergency Services); accurately assess the respiratory status of one (1) resident requiring ventilator services and perform an accurate assessment of one (1) resident with a known change in condition. Residents' #145, #37 #5, and # 98.

A. Based on observations, record review and staff interview for five (5) of 55 sampled residents, it was determined that facility staff failed to provide the necessary care and services to ensure residents attain or maintain the highest practicable physical, mental, and/or psychosocial well-being as evidenced by facility staff ' s failure to: consistently assess and monitor the status of one (1) resident who exhibited a change in status as manifested by low blood pressure, increased respirations and [MEDICAL CONDITION](rapid heart rate) and failed to administer a [MEDICATION NAME][MEDICATION NAME] treatment ([MEDICATION NAME]) as ordered for the same resident; failed to perform an accurate assessment for one (1) resident who sustained a change in condition to include elevated heart rate, increased respirations, and decreased oxygen saturation; to consistently assess and monitor one (1) resident who was ventilator dependent and experienced [MEDICAL CONDITION] assess and identify the need for one (1) resident who had an accumulated white coating on his/ her tongue; and failed to ensure that one (1) resident wore protective head gear and that the head circumference was measured in accordance to physician's orders [REDACTED].#145 (is affiliated with the immediate jeopardy scope and severity), #37, #5, #104 and #143. An Immediate Jeopardy (IJ) was identified at 42 CFR 483.25; F309 Provide Care/ Services for Highest Well Being for Failure to prevent neglect: Lack of supervision for individuals with known special needs and Failure to monitor and intervene for serious medical conditions. The notification of the IJ was made on September 22, 2015 (Tuesday) at 2:20 PM. The facility's Administrator provided a letter noting a corrective action plan inclusive of staff training on multiple aspects of the provision of respiratory care to licensed nursing staff and respiratory therapists. A review of the IJ action plan was removed on September 25, 2015 at 6:00 PM. Subsequently, the deficiency was identified at a scope and severity of E. The findings include: 1. Facility staff failed to identify, comprehensively assess and monitor Resident #145 when he/she demonstrated change in status as evidenced by repeated complaints of shortness of breath, refusal of respiratory treatments ([MEDICAL CONDITION] - Continuous Positive Airway Pressure - breathing treatment) and alteration in level of arousal. The resident began complaining of shortness of breath on August 29, 2015, refused [MEDICAL CONDITION] treatments beginning August 28, 2015 and demonstrated an alteration in the level of arousal on August 31, 2015. On August 31st at approximately 9:03 PM, Resident #145 sustained low blood pressure, increased respirations and [MEDICAL CONDITION] Subsequently, the resident was transferred to the nearest emergency room (ER) and was hospitalized in intensive care. Resident #145 was admitted on [DATE]. According to the admitting history and physical examination [REDACTED]. According to clinical record entries documented by respiratory therapy; in S-BAR format (situation/background/assessment/recommendation) the following was revealed: (August 28, 2015 to) August 29, 2015 - 7PM-7AM- Shift Report - Patient refused [MEDICAL CONDITION] trails last night; Sat = 99% (oxygen saturation), (Heart Rate) 79, (Respiratory Rate) 24. Alert (and) stable. Patient has a lot of thick tan to white (oral) secretions. Continue to encourage patient to get weaned .[MEDICAL CONDITION] 5/10 x10(minutes), back on AC (assist control) due to patient complaining of SOB (shortness of breath) August 30, 2015 - 7AM-7PM- Shift Report - Received (patient) on AC mode, (nebulization treatment) given as ordered. (Patient) . (Illegible writing). (oxygen saturation) -99%, HR (illegible writing), Will continue to monitor patient. Special procedures done .Attempt to wean. Pt (Patient) on [MEDICAL CONDITION] trial. (Patient) keep comp (complaining) of SOB (shortness of breath), anxious. Placed back on AC (Assist Control) mode to rest. (August 30, 2015 to) August 31, 2015- 7PM-7AM- S- (Patient) is on AC 15/(Tidal Volume)-500, (Fractioned of Inspired Oxygen-45%, (Peep)-5, B- [MEDICAL CONDITION], A- Pt stable throughout shift- Sat-98%. HR-79, RR (Respiratory Rate) -21. Pt complains of being unable to breathe but in no apparent distress. Continue to monitor for changes. August 31, 2015- 7AM-7PM- S- Pt remains on AC mode, O (No) active weaning do (due) to pt being less arousable in PM. B- [MEDICAL CONDITION], A- Alert (male/female), HR-84- RR-25, Sat-98%, small thin pale secretions, BS (breath sounds) clear, R- Will continue to monitor. August 31, 2015 Ventilator Flow Sheet (recorded by respiratory therapist) revealed the following Rate Set/Total on the A/C mode: (Rate Set/Total defined: 15/34 - 15 reflects ventilator preset respiratory rate and 34 reflects - resident breaths above the set rate) 0130 (1:30 AM) - 15/34 - (Oxygen) Saturation(normal range 95 - 100%) - 97%, Heart Rate- 87 0425 (4:25 AM) - 15/33 - (Oxygen) Saturation- 98%, Heart Rate-93 0855 (8:55 AM) - 15/32 - (Oxygen) Saturation-98%, Heart Rate-87 1230 (12:30 PM) - 15/33 - No Oxygen Saturation and Heart Rate documented in the allotted space. (1700) 5:00 PM - 15/29 - (Oxygen) - 98%, Heart Rate-80 2045 (8:45 PM) - 15/23, Saturation 96%, Heart Rate- 158. The nurse practitioner documented a change in Resident #145 as follows: August 31, 2015 (no time indicated) - Certified Registered Nurse Practitioner . Initial Psych (psychiatric) and Mental Status Exam: Information obtained from staff/chart/resident (not) easily arousable . (Patient) not arousable and does not answer questions at this time. Staff reports resident Alert and Oriented x3- (time, person and place), but just received pain meds. Concerns/Findings: Per staff resident normally (Alert and oriented x3), responds to questions asked. On exam, resident responding to painful stimuli but not easily arousable and (he/she) opens eyes to name but does not answer question, (-) [MEDICAL CONDITION], + (Positive) Anxiety, + mood and affect (secondary to medical complications/conditions per staff. Plans: Monitor for safety and fall precautions, monitor for worsening anxiety, (Follow-up) in one (1) week to reassess mood/and anxiety. The record revealed that nursing staff communicated to the nurse practitioner that the resident was not arousable due to just received pain medication . However, a review of the August 2015 Medication Administration Record [REDACTED]. The specific time was not noted. Further review of the MAR indicated [REDACTED]. There was no documented evidence that Resident #145 sustained lack of arousal associated with any preceding dosages of Tylenol administration or just received pain medication. Nursing Notes: August 28, 2015 3:13 PM - .V/S (vital signs): (b/p-blood pressure) 108/58; (P-pulse) 99; (R-respirations) 18 . no acute distress noted August 29, 2015 3:00 AM - . (b/p) 116/62; (P) 78, (R) 20 . August 31, 2015- 12:35 PM - Resident remain alert and responsive. Vent (ventilator) dependent AC mode for respiratory support. Suction PRN (as needed) .V/S- (Blood Pressure) - 134/74, 98.9 (Temperature)-, 74, 100 (two (2) different heart rates) no respirations documented . S-BAR (Situation-Background-Assessment-Recommendation) /Acute Change in Condition Report: Situation- Date: August 31, 2015, Time: 9:39 PM (of note, this is the successive nursing note to the August 31st 12:35 PM entry) . low B/P- 77/53, P-153, R-24, lethargy (and) gasping for breath, although on vent. Background: [MEDICAL CONDITION], Temp: 98.6, B/P- 77/53, RESP: 24, Pulse: 153, Lung sounds: Crackles, Pulse ox: 93% ventilator . Resident was noted (with) (decreased) B/P 77/53, elevated pulse rate. House officer notified who ordered to transport resident to (hospital) for further evaluation and treatment. There was no evidence that licensed nursing and respiratory staff identified that Resident #145 exhibited progressive change in status (respiratory and mental) that warranted monitoring and/or intervention before the resident became obtunded, unresponsive with agonal breathing requiring transfer to higher level of care. August 31, 2015- 2103 (9:03 PM) - Hospitalist (physician) Note: I was called to evaluate (Resident #145) b/c (because) of [MEDICAL CONDITIONS] (and) acute AMS gradually since few hours ago. (His/her) HR (heart rate) has been elevated to 150 ' s (and) B/ P as low as 77/53. As per nurse even to earlier today (he/she) was A&O (alert and oriented), but currently (he/she) is obtunded (diminished arousal and awareness) (and) unresponsive with agonal (gasping) breathing. (He/she) is quadriplegic. Assessment/Plan: Acute AMS (and) [MEDICAL CONDITION]- unknown cause ((he/she) finished (his/her) IV (Intravenous)[MEDICATION NAME](antibiotic) yesterday (and) [MEDICATION NAME] (anti-fungal medication) was discontinued). Transfer to nearest ER (emergency room ). The clinical record lacked evidence that nursing notified the physician regarding the resident's progressive complaint of having shortness of breath, refusing [MEDICAL CONDITION] trials, alteration in the level of arousal from August 28, 2015 to August 31, 2015 until 9:03PM when the resident was obtunded and with agonal breathing. Interviews A face-to-face interview was conducted with Employee #14 (on-coming day-shift team member, August 31, 2015 7AM - 7PM) September 18, 2015 at approximately 2:00 PM regarding the above aforementioned concerns. He/she said that the off-going team member (night shift August 30th 7PM through August 31, 2015 7AM) stated that the resident was calling all night, using the type of call bell one blows into. Employee #14 further stated the off-going therapist and the nurse was in and out of the resident ' s room all night. Employee #14 acknowledged the physician should have been informed of the resident's restlessness, complaint of having shortness of breath and refusal of [MEDICAL CONDITION] treatments. A review of records obtained from the acute care facility that the resident was transferred to revealed the following physician ' s entry dated 8/31/15: .(Resident #145) presented to the ED (Emergency Department) from NH (Nursing Home) with acute AMS (Altered Mental Status), [MEDICAL CONDITIONS] fever of 107. In ED, (Temperature) - 41.7(Celsius- converted to Fahrenheit- 107.6 degrees); (Heart Rate-85); Respirations-16; Blood Pressure (Systolic/Diastolic) 87/48. The clinical record was reviewed September 18, 2015. Cross referenced 483.25(k) F328; 483.20(k)(3)(ii) F282; 483.30(a) F353; 483.10(b)(11) F157 2. Facility staff failed to perform an accurate assessment for Resident #37 that experienced a documented change in condition. The respiratory therapy staff assessment was inconsistent with the resident's status as reflected in the nurse's and physician ' s assessments on September 18, 2015 at 5:00 PM and 5:30 PM; respectively. Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review was conducted on September 21, 2015 at 9:40 AM. The review of clinical notes revealed inconsistencies in the assessment of Resident #37 status on September 18, 2015 at 5:00 PM as it relates to entries documented by medical staff, nursing staff, and respiratory staff. The inconsistencies are as follows: Review of the Ventilator Flow Sheet dated September 18, 2015 revealed the respiratory therapy staff documented pre- treatment assessment at 5:00 PM which indicated the heart rate- 89 beats per minute, respiratory rate- 19 breaths per minute, and oxygen saturation- 98 percent; and post-treatment assessment at 5:15 PM indicating heart rate was 90 beats per minute, respiratory rate 16 breaths per minute and oxygen saturation of 98%. The nursing staff documented an ' Acute Change in Condition Report ' dated September 18, 2015 at 5:00 PM secondary to resident with elevated irregular heart rate of 166 beats per minute and oxygen saturation of 81% while on the ventilator with FiO2 of 40%. physician progress notes [REDACTED]. According to the medical staff assessment, the resident was noted to have a heart rate of 166 beats per minute, blood pressure of 125/56 millimeter of Mercury. Although the medical and nursing staff assessed Resident #37 to have experienced a change in condition to include elevated heart rate, increased respirations, and decreased oxygen saturation, the respiratory therapy staff documented an assessment with the heart rate, respiratory, and oxygen saturation consistent with Resident #37 ' s baseline physical assessments. Resident #37 was subsequently transferred via Emergency Medical Services to a local emergency department. A face to face interview was conducted with Employee #31 on September 21, 2015 at approximately3:30 PM. S/he confirmed that the respiratory assessment was inconsistent with the change of condition at the time of assessment. The findings were reviewed, discussed, and acknowledged. 3. Facility staff failed to consistently assess and monitor Resident #5 who was ventilator dependent and experienced an increase in heart rate and was subsequently sent out 911 (Emergency Services). A review of Resident #5 ' s quarterly MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of April 22, 2015 revealed [DIAGNOSES REDACTED]. According to physician's order [REDACTED]. Physician ' s Progress Notes: Pulmonary Note - June 1, 2015 at 1:45 PM revealed Patient (resident) remains on vent. Responds to stimuli, no purposeful movements. Vent settings AC (mode of Assist Control) 10, VT (tidal volume) 500, PEEP (positive expiratory end pressure) +5, Fi02 (room air) 40%. Exam: vitals 104/72, P 69, R 18, T 97.9; CTA-(clear to auscultation bilaterally no wheezes; CVS (cardiovascular) no murmurs; Abd (abdomen) + (positive) bs (bowel sounds); Ext (extremities) no [MEDICAL CONDITION] .A/P Assessment/Plan (1) chronic [MEDICAL CONDITION]; (2) [MEDICAL CONDITIONS]([MEDICAL CONDITION]) - Continue on vent support - no weaning - supportive care. MD (Medical Doctor) Acute Note - June 2, 2015 at 08:50 AM revealed Responding to Rapid Response. Patient (Resident) identified with [MEDICAL CONDITION] HR (140), SBP (systolic blood pressure 110, RR (respiratory rate) 20s-30s; SAT (Saturation) 96%, 100% Fi02 with ambu bagging. Emesis, tube feeding witnessed; lung (+) Rhonchi, R (right) CTA (clear to auscultation) left. CVS: [MEDICAL CONDITION].ABD: distended .hypo (hypoactive) bowel sounds; ENT (Ear, Nose, Throat) [MEDICAL CONDITION] BUE (bilateral upper extremities), R (right) > (greater than) L (left). Warm extremities; A/P (Assessment/Plan) : Respiratory Distress, R/O aspiration/sepsis. Will send to ER (emergency room ) v (by) 911. A review of the nursing notes revealed the following: May 31, 2015 4:50 AM - Resident is alert and responsive. AM care given, vs (vital signs) 98.4 temperature, P (pulse) 77 R(respirations) 16, BP (blood pressure)127/68, Pulse OX (oximetry) 96%. No evidence of pain noted. IS Care given will continue to monitor . May 31, 2015 6:30 PM - Resident is alert and responsive due medications given as ordered. No abnormal findings noted. Vs T 98.2, P 86 R 20, BP 133/78. Pulse Ox 96%. Will continue to monitor. June 1, 2015 4:00 PM - Resident is alert and responsive PM care given. Vs T 98.6, P 87, R 20, BP 130/77 Pulse OX 98%. Turned and repositioned, due meds give. June 2, 2015 5:00 AM - Resident is alert. On vent (ventilator) dependent for support.[MEDICAL CONDITION] and suction care provided. Total care with ADL (Activities of Daily Living). Enteral Feeding in progress. Peg (percutaneous endoscopic gastrostomy) tube patent and flushed well. Will monitor. Vs (BP) 131/72, (P) 76, (R) 18, (T) 98.3. June 2, 2015- 8:35 AM- SBAR (Situation, Background, Assessment, Recommendation)/Acute change in condition. Resident was noted with respiratory distress and an elevated HR (heart rate) of 140 (bpm/beats per minute). Resident was bagged by RT (Respiratory Therapy) while Rapid Response was called. Rapid Response team responded In house officer gave new order to transfer resident via (by) 911 (Emergency). Emesis (vomiting) noted x (times) 1 (one) during bagging with [MEDICAL CONDITION] activity. Resident was then transferred via 911 to (local hospital). Respiratory Therapy Notes: A review of the Respiratory Ventilator Flow Sheet for June 2, 2015 revealed the following: Date: June 2, 2015 Time: 0025 (12:25 AM) Mode: AC Fi02: 40% PEEP: 5 Saturation: 97% Heart Rate: 70 Date: June 2, 2015 Time: 0345 (3:45 AM) Mode: AC Fi02: 40% PEEP 5 Saturation: 98% Heart Rate: 121 Date: June 2, 2015 Time: 08:20 (8:20 AM) Mode: AC Fi02: 40% PEEP: 5 Saturation: 99% Heart Rate: 129 There was no documented evidence that the physician was notified in regards to Resident #5 ' s increased heart rate from June 2, 2015 (3:45 AM) to June 2, 2015 (08:20 AM), which is indicative of approximately 4 hours. A review of the respiratory therapy shift note revealed : June 2, 2015 - 7pm-7am shift note revealed: S: Pt on A/C mode B: Respiratory resident A: Sat 98% HR 71, RR 18 BS (breath sounds) Rhonchi/clear, sxn (suction) moderate yellow suction, no distress. R: monitor June 2, 2015 -7AM- 7PM Shift- no documentation under shift report; indicated on flow sheet- PT (Patient) transferred to area Hospital. The clinical record lacked evidence that facility staff assessed and monitored Resident #5 when the resident ' s heart rate increased. The physician was not notified when the resident ' s became [MEDICAL CONDITION](increased heart rate) , which was first documented on June 2, 2015 at 3:45 AM to be 121. The resident ' s condition declined as evidenced by increased [MEDICAL CONDITION](HR elevated to 129). A rapid response was called and resident was subsequently transferred to the emergency room via 911 (Emergency Medical Services) according to the SBAR at the time of transport the residents heart rate of 140. A face-to-face interview was conducted on September 21, 2015 at approximately 10:30 AM with Employees #18 and #47. Employee #18 state that his/her shift is 7:00AM to 7:00PM. Employee #18 also state, when he/she first saw the resident with the heart rate 129 is when the rapid response (When a resident's condition changes (based on predetermined criteria) and requires an assessment by a physician to stabilize his/her condition and prevent further deterioration) was called at approximately 8:20AM, the resident vomited when he/she was bagged. Employee #47 stated when he/she was conducting rounds from the rooms assigned he/she was called to the rapid response by Employee #18 who stated that the rapid response took over, and that the resident had vomited when he/she was bagged and then the resident was sent out 911 with a heart rate at 140. The night shift nurse was not available for interview. The clinical record was reviewed on September 21, 2015. 4. Facility staff failed to assess and identify the need for medical intervention for Resident #104, who had accumulated white colored [MEDICAL CONDITION] on his/her tongue. A review of documentation related to Activities of Daily Living (ADL) performed on behalf of Resident #104 and through staff interview, it was determined that oral care was consistently provided each shift by facility staff. However, there was no evidence that facility staff identified the need for medical intervention to address the white substance on the resident ' s tongue. Following the survyeor's query, the resident was examined by the medical team and subsequently diagnosed with [REDACTED]. According to, The Lippincott Manual of Nursing Practice, Ninth Edition-2010, pp 613, revealed: Conditions of the Mouth and Jaw Candidiasis- Candidiasis is a fungal infection commonly caused by [MEDICAL CONDITION][MEDICATION NAME]. It usually occurs in the mouth . Candidiasis can become a source of systemic dissemination, particularly in high-risk persons, Clinical Manifestations: (1.) Oral discomfort, burning, altered taste, [DIAGNOSES REDACTED], (2) White, raised, painless plaques, loosely adherent, (3) Possible spread to the esophagus with pain on swallowing and chest pain Management: Topical antifungal agents in oral rinses, [MEDICATION NAME], or creams, such as [MEDICATION NAME] or [MEDICATION NAME] . [MEDICATION NAME] for pain ., Nursing Assessment: Assess extent of [MEDICAL CONDITION] and inflammation in mouth . 2. Assess level of pain . Patient Education and Health Maintenance: (2) Instruct high-risk patients about daily oral examination and signs and symptoms to observe (3). Encourage good oral hygiene An observation of the Resident #104 during the survey period revealed the following: On September 10, 2015 at approximately 4:28 PM- Resident #104 ' s tongue was observed completely coated with a white substance. A second attempt was made on September 14, 2015 at approximately 12Noon to visualize Resident #104 ' s oral cavity with Employee #15. A visualization of the resident ' s oral cavity was unsuccessful because the resident rejected the employee ' s attempt to open his/her mouth. This surveyor conveyed to Employee #15 the concern related to the observation of the white substance on the resident ' s tongue. Employee #15 informed the Nurse Practitioner who evaluated the resident and diagnosed him/her with Oral Candidiasis as follows: Nurse Practitioner note dated September 14, 2015 at 4:10 PM read: Asked to evaluate resident with c/o (complaint of) whitish coating on tongue. Resident is bedbound and clamps mouth close (with) difficulty to adequately view oral cavity. Assessment done (with) aid of primary nurse, = whitish coating on tongue. Attempted to clear tongue with mouth care kit (without) any effect on mouth/tongue coating. (No) distress. A (Assessment):- Oral Candidiasis (Thrush). Plan: [MEDICATION NAME] solution 100,000 units/ml. Apply 5 ml (millimeters) to tongue and clean tongue QID (four times a day) (times) 14 days. Reassess for any adverse changes. Facility staff failed to assess and identify the need for medical intervention for Resident #104 whose tongue was observed coated with a white substance. Resident #104 was totally dependent and facility staff must anticipate the resident ' s needs as evidenced by the annual Minimum Data Set (MDS) assessment dated [DATE]. Section B, Hearing, Speech, and Vision was coded that Resident 104 was unable to speak and was rarely/never understood. Under Section C, Cognition, the resident was coded as severely cognitively impaired and never/rarely made decisions, Section I (Active Diagnoses) included: [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], Craniotomy, Dysphagia. Section G (Functional Status) revealed the resident was coded as being totally dependent with one person for physical assist and personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth .). physician's order [REDACTED]. A review of clinical documentation (ADL sheets and Treatment Administration Records) for the months of August and September 2015 revealed staff documented that oral care was provided every shift. An interim physician's order [REDACTED].-fungal medication) Oral Suspension 100,000 units per ml. Apply 5 ml (millimeters) to tongue and clean tongue QID (four times a day) (times) 14 days for thrush. A review of the resident ' s CNA (nursing assistant) Charting flow sheets from September 7, 2015 through September 15, 2015 revealed, Personal Hygiene: Resident required one person physical assist to provide all hygiene tasks (oral care included), with no self-performance. The comprehensive care plan updated August 11, 2015 included the following problem: Alteration in ADL (Activities of Daily Living) function (secondary) to [DIAGNOSES REDACTED]. Staff to provide oral, hair and nail care qd (every day) and prn (as needed) . There was no evidence that facility staff provided oral care consistent with the resident's need. A face-to-face interview was conducted with Employees #15 and #17 on September 14th at approximately 1:00 PM. When queried about how the resident ' s mouth care is performed and the frequency, he/she stated; It is done every day, and an oral swab is used and s/he stated there was no white coating on the resident ' s tongue. He/she further stated sometimes white secretions are in his/her mouth but they are suctioned out, and the mouth and tongue is cleaned every shift. The clinical record was reviewed on September 15, 2015. 5. Facility staff failed to ensure that Resident #143 wore protective head gear and underwent head circumference measurements weekly in accordance with physician's order [REDACTED]. On September 16, 2015 at approximately 11:45 AM and 2:00 PM. Staff was observed sitting in chair, near the window at the foot of Resident # 143 ' s bed. The resident was observed asleep, lying in bed on his/her back. A white mitten was observed on the right hand. He/she was covered with a white sheet. A helmet was positioned on the foot board. A face to face interview was conducted with Employee #48 at the time of the observation. Employee #48 was queried about the scheduled times the resident was supposed to wear the helmet. He/she stated; He/she is supposed to wear the helmet when he/she is out of bed. Employee #48 further stated that the resident was on one to one (1:1) observation. A physician's orders [REDACTED]. Remove every 2 (two) hours to check skin integrity. Document in chart. Measure head circumference weekly. Report increase in size to MD (Medical Doctor). A review of the clinical record (Medication and Treatment Administration records MAR/TAR and nurse's notes) for the period of August 27, 2015 through September 16, 2015 lacked evidenced that Resident #143 ' s head circumference was measured weekly in accordance with physician's orders [REDACTED]. A face-to-face interview was conducted with Employee #18 on September 16, 2015 at approximately 2:31 PM. He/she acknowledged the aforementioned findings. The observation and clinical record was conducted on September 16, 2015. B. Based on record review and staff interview for seven (7) of 55 sampled residents, it was determined the facility staff failed to: conduct comprehensive pain assessments to include characteristics such as intensity, type, pattern of pain, location, frequency and duration of pain for seven (7) residents; consistently assess two (2) residents response to pain intervention. Residents ' #64, #108, #107, #142, #80, #43 and #49. The findings include: Facility ' s Policy -Pain Assessment and Management policy Copyright 2001 MED_PASS, INC (Revised October 2010) stipulates Steps in the Procedure Recognizing Pain: 1. Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain .Assessing Pain: 1. During Comprehensive pain assessment gather the following information as indicated from the resident (or legal representative): a. History of pain and its treatment .b. Characteristics of pain: (1) Intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g. constant or intermittent); (4) Location and [MEDICAL CONDITION] of pain; (5) Frequency, timing and duration of pain; c. Impact of pain on quality of life; d. Factors that precipitate or exacerbate pain; e. Factors and strategies that reduce pain; and f. Symptoms that accompany pain (e.g. nausea, anxiety) .Identifying the Causes of Pain .Define Goals and Appropriate Interventions .Implement Pain Management Strategies1. Non-pharmacological interventions .; 2. Pharmacological interventions .; 4. The physician and staff will establish a treatment regimen based on consideration of the following a. The resident ' s medical condition; b. Current medication regimen; c. Nature, severity and cause of the pain; d. Course of the illness; and e. Treatment goals .6. Implement the medication regimen as ordered, carefully documenting the results of the interventions .Monitoring and Modifying Approaches .Documentation 1. Document the resident ' s reported level of pain with adequate details (i.e. enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. 2. Upon completion of the pain assessment, the person conducting the assessment shall record the information obtained from the assessment in the resident ' s medical record. 1. Facility staff failed to conduct comprehensive pain assessment and/or reassessment to include characteristics such as intensity, type, pattern of pattern, location, frequency and duration of pain for resident #64 A review of the medical record revealed Resident #64 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident #64 was transferred out to a local emergency department on September 1, 2015 to manage change in mental status . Review of medical record conducted on September 14, 2015 revealed Resident #64 has a documented community-acquired Stage IV sacral pressure ulcer present on admission which last measured 15 X 16.5 X 3.5 centimeters according to the Wound and Skin Care Progress Note dated August 31, 2015. According to the physician's order [REDACTED]. July 15, 2015- [MEDICATION NAME] 50 milligrams via [DEVICE] (gastrostomy tube) three times a day prior to wound care August 24, 2015 at 2:10 PM- Discontinue [MEDICATION NAME] 50 milligrams; Start [MEDICATION NAME] 100 milligram by mouth 30 minutes prior to wound treatment three times per day then one (1) by mouth every eight (8) hours as needed pain August 31, 2015 at 1:00 PM- Discontinue [MEDICATION NAME] order; Start Oxy IR (Immediate Release) 5 milligram by mouth one tab 30 minutes prior to wound treatment every shift and every eight (8) hours as needed for pain September 1, 2015 at 3:15 PM- Discontinue Oxy IR (Immediate Release)order; start [MEDICATION NAME] 100 milligram three times daily by mouth for neuropathic pain; Tylenol ES (Extra Strength) 500 milligrams by mouth three times daily 30 minutes prior to wound treatment every shift for pain Review of the Physician ' s Progress

Based on record review and staff interviews for four (4) of 55 sampled residents, it was determined that the facility staff failed to ensure that residents received the necessary care and treatment relative to ventilator services as evidenced by failure to: recognize, assess and monitor potential complications for one (1) ventilator dependent resident who demonstrated symptoms of respiratory dysfunction for greater than 24 hours; and was subsequently transferred via 911 to an emergency department and hospitalized in intensive care; failure recognize, assess and monitor potential complications for one (1) resident who was ventilator dependent and experienced an increase in heart rate ([MEDICAL CONDITION] and was subsequently transferred via 911 to an emergency department ; accurately assess the respiratory status of one (1) resident requiring ventilator services and perform an accurate assessment of one (1) resident with a known change in condition. Residents #145 (is affiliated with the immediate jeopardy scope and severity), 37, 5, and 98. An Immediate Jeopardy (IJ) was identified at 42 CFR 483.25(k); F328 Special Needs; ensure that residents receive proper treatment and respiratory care for Failure to prevent neglect: Lack of supervision for individuals with known special needs and Failure to monitor and intervene for serious medical conditions. The notification of the IJ was made on September 22, 2015 (Tuesday) at 2:20 PM. The facility's Administrator provided a letter noting a corrective action plan inclusive of staff training on multiple aspects of the provision of respiratory care to licensed nursing staff and respiratory therapists. A review of the IJ action plan was removed on September 25, 2015 at 6:00 PM. Subsequently, the deficiency was identified at a scope and severity of E. The findings include: Facility staff failed to recognize and assess factors that placed Resident #145, who was ventilator dependent, at risk for complications as evidenced by the resident ' s repeated complaints of shortness of breath, refusal of respiratory treatments ([MEDICAL CONDITION] - Continuous Positive Airway Pressure - breathing treatment) and alteration in level of arousal. The resident began complaining of shortness of breath on August 29, 2015, refused [MEDICAL CONDITION] treatments beginning August 28, 2015 and demonstrated an alteration in the level of arousal on August 31, 2015. On August 31st at approximately 9:03 PM, Resident #145 sustained low blood pressure, increased respirations and [MEDICAL CONDITION] Subsequently, the resident was transferred to the nearest emergency room (ER) and was hospitalized in intensive care. Resident #145 was admitted on [DATE]. According to the admitting history and physical examination [REDACTED]. According to clinical record entries documented by respiratory therapy; in S-BAR format (situation/background/assessment/recommendation) the following was revealed: (August 28, 2015 to) August 29, 2015 - 7PM-7AM- Shift Report - Patient refused [MEDICAL CONDITION] trails last night; Sat = 99% (oxygen saturation), (Heart Rate) 79, (Respiratory Rate) 24. Alert (and) stable. Patient has a lot of thick tan to white (oral) secretions. Continue to encourage patient to get weaned .[MEDICAL CONDITION] 5/10 x10(minutes), back on AC (assist control) due to patient complaining of SOB (shortness of breath) August 30, 2015 - 7AM-7PM- Shift Report - Received (patient) on AC mode, (nebulization treatment) given as ordered. (Patient) . (Illegible writing). (oxygen saturation) -99%, HR (illegible writing), Will continue to monitor patient. Special procedures done .Attempt to wean. Pt (Patient) on [MEDICAL CONDITION] trial. (Patient) keep comp (complaining) of SOB (shortness of breath), anxious. Placed back on AC (Assist Control) mode to rest. (August 30, 2015 to) August 31, 2015- 7PM-7AM- S- (Patient) is on AC 15/(Tidal Volume)-500, (Fractioned of Inspired Oxygen-45%, (Peep)-5, B- [MEDICAL CONDITION], A- Pt stable throughout shift- Sat-98%. HR-79, RR (Respiratory Rate) -21. Pt complains of being unable to breathe but in no apparent distress. Continue to monitor for changes. August 31, 2015- 7AM-7PM- S- Pt remains on AC mode, O (No) active weaning do (due) to pt being less arousable in PM. B- [MEDICAL CONDITION], A- Alert (male/female), HR-84- RR-25, Sat-98%, small thin pale secretions, BS (breath sounds) clear, R- Will continue to monitor. August 31, 2015 Ventilator Flow Sheet (recorded by respiratory therapist) revealed the following Rate Set/Total on the A/C mode: (Rate Set/Total defined: 15/34 - 15 reflects ventilator preset respiratory rate and 34 reflects - resident breaths above the set rate) 0130 (1:30 AM) - 15/34 - (Oxygen) Saturation(normal range 95 - 100%) - 97%, Heart Rate- 87 0425 (4:25 AM) - 15/33 - (Oxygen) Saturation- 98%, Heart Rate-93 0855 (8:55 AM) - 15/32 - (Oxygen) Saturation-98%, Heart Rate-87 1230 (12:30 PM) - 15/33 - No Oxygen Saturation and Heart Rate documented in the allotted space. (1700) 5:00 PM - 15/29 - (Oxygen) - 98%, Heart Rate-80 2045 (8:45 PM) - 15/23, Saturation 96%, Heart Rate- 158. Nursing Notes: August 28, 2015 3:13 PM - .V/S (vital signs): (b/p-blood pressure) 108/58; (P-pulse) 99; (R-respirations) 18 . no acute distress noted August 29, 2015 3:00 AM - . (b/p) 116/62; (P) 78, (R) 20 . August 31, 2015- 12:35 PM - Resident remain alert and responsive. Vent (ventilator) dependent AC mode for respiratory support. Suction PRN (as needed) .V/S- (Blood Pressure) - 134/74, 98.9 (Temperature)-, 74, 100 (two (2) different heart rates) no respirations documented . S-BAR (Situation-Background-Assessment-Recommendation) /Acute Change in Condition Report: Situation- Date: August 31, 2015, Time: 9:39 PM (of note, this is the successive nursing note to the August 31st 12:35 PM entry) . low B/P- 77/53, P-153, R-24, lethargy (and) gasping for breath, although on vent. Background: [MEDICAL CONDITION], Temp: 98.6, B/P- 77/53, RESP: 24, Pulse: 153, Lung sounds: Crackles, Pulse ox: 93% ventilator . Resident was noted (with) (decreased) B/P 77/53, elevated pulse rate. House officer notified who ordered to transport resident to (hospital) for further evaluation and treatment. There was no evidence that licensed nursing and respiratory staff identified that Resident #145 exhibited progressive change in status (respiratory and mental) that warranted monitoring and/or intervention before the resident became obtunded, unresponsive with agonal breathing requiring transfer to higher level of care. August 31, 2015- 2103 (9:03 PM) - Hospitalist (physician) Note: I was called to evaluate (Resident #145) b/c (because) of [MEDICAL CONDITIONS] (and) acute AMS gradually since few hours ago. (His/her) HR (heart rate) has been elevated to 150 ' s (and) B/ P as low as 77/53. As per nurse even to earlier today (he/she) was A&O (alert and oriented), but currently (he/she) is obtunded (diminished arousal and awareness) (and) unresponsive with agonal (gasping) breathing. (He/she) is quadriplegic. Assessment/Plan: Acute AMS (and) [MEDICAL CONDITION]- unknown cause ((he/she) finished (his/her) IV (Intravenous)[MEDICATION NAME](antibiotic) yesterday (and) [MEDICATION NAME] (anti-fungal medication) was discontinued). Transfer to nearest ER (emergency room ). The clinical record lacked evidence that nursing and respiratory staff recognized and communicated to the physician, the resident's progressive complaint of having shortness of breath, refusing [MEDICAL CONDITION] trials, alteration in the level of arousal from August 28, 2015 to August 31, 2015 until 9:03PM, when the resident was obtunded and with agonal breathing. Interviews A face-to-face interview was conducted with Employee #14 (on-coming day-shift team member, August 31, 2015 7AM - 7PM) September 18, 2015 at approximately 2:00 PM regarding the above aforementioned concerns. He/she said that the off-going team member (night shift August 30th 7PM through August 31, 2015 7AM) stated that the resident was calling all night, using the type of call bell one blows into. Employee #14 further stated the off-going therapist and the nurse was in and out of the resident ' s room all night. Employee #14 acknowledged the physician should have been informed of the resident's restlessness, complaint of having shortness of breath and refusal of [MEDICAL CONDITION] treatments. A review of records obtained from the acute care facility that the resident was transferred to revealed the following physician ' s entry dated 8/31/15: .(Resident #145) presented to the ED (Emergency Department) from NH (Nursing Home) with acute AMS (Altered Mental Status), [MEDICAL CONDITIONS] fever of 107. In ED, (Temperature) - 41.7(Celsius- converted to Fahrenheit- 107.6 degrees); (Heart Rate-85); Respirations-16; Blood Pressure (Systolic/Diastolic) 87/48. The clinical record was reviewed September 18, 2015. Cross referenced 483.25 F309; 483.30(a) F353; 483.10(b)(11) F157 2. Facility staff failed to perform an accurate assessment for Resident #37 that experienced a documented change in condition. The respiratory therapy staff assessment was inconsistent with the resident's status as reflected in the physician and nurse's assessment on September 18, 2015 at 5:30 PM and 5:00 PM; respectively. Resident #37 was admitted on [DATE] with [DIAGNOSES REDACTED]. Medical record review was conducted on September 21, 2015 at 9:40 AM. The review of clinical notes revealed inconsistencies in the assessment of Resident #37 status on September 18, 2015 at 5:00 PM as it relates to entries documented by medical staff, nursing staff, and respiratory staff. The inconsistencies are as follows: physician progress notes [REDACTED]. According to the medical staff assessment, the resident was noted to have a heart rate of 166 beats per minute, blood pressure of 125/56 millimeter of Mercury. The nursing staff documented an ' Acute Change in Condition Report ' dated September 18, 2015 at 5:00 PM secondary to resident with elevated irregular heart rate of 166 beats per minute and oxygen saturation of 81% while on the ventilator with FiO2 of 40%. Review of the Ventilator Flow Sheet dated September 18, 2015 revealed the respiratory therapy staff documented pre- treatment assessment at 5:00 PM which indicated the heart rate- 89 beats per minute, respiratory rate- 19 breaths per minute, and oxygen saturation- 98 percent; and post-treatment assessment at 5:15 PM indicating heart rate was 90 beats per minute, respiratory rate 16 breaths per minute and oxygen saturation of 98%. Although the medical and nursing staff assessed Resident #37 to have experienced a change in condition to include elevated heart rate, increased respirations, and decreased oxygen saturation, the respiratory therapy staff documented an assessment with the heart rate, respiratory, and oxygen saturation consistent with Resident #37 ' s baseline physical assessments. Resident #37 was subsequently transferred via Emergency Medical Services to a local emergency department. A face to face interview was conducted with Employee #31 on September 21, 2015 at approximately3:30 PM. S/he confirmed that the respiratory assessment was inconsistent with the change of condition at the time of assessment. The findings were reviewed, discussed, and acknowledged. 3. Facility staff failed to recognize and assess factors that potentially placed Resident #5, who was ventilator dependent, at risk for complications as evidenced by failure assess and monitor the resident when he/she experienced an increase in heart rate and subsequent compromise in respiratory function. The resident was subsequently sent out 911 (Emergency Services). A review of Resident #5's quarterly MDS (Minimum Data Set) with an Assessment Reference Date (ARD) of April 22, 2015 revealed [DIAGNOSES REDACTED]. physician's orders [REDACTED]. Physician ' s Progress Notes: Pulmonary Note - June 1, 2015 at 1:45 PM revealed Patient (resident) remains on vent. Responds to stimuli, no purposeful movements. Vent settings AC (mode of Assist Control) 10, VT (tidal volume) 500, PEEP (positive expiratory end pressure) +5, Fi02 (room air) 40%. Exam: vitals 104/72, P 69, R 18, T 97.9; CTA-(clear to auscultation bilaterally no wheezes; CVS (cardiovascular) no murmurs; Abd (abdomen) + (positive) bs (bowel sounds); Ext (extremities) no [MEDICAL CONDITION] .A/P Assessment/Plan (1) chronic [MEDICAL CONDITION]; (2) [MEDICAL CONDITIONS]([MEDICAL CONDITION]) - Continue on vent support - no weaning - supportive care. MD (Medical Doctor) Acute Note - June 2, 2015 at 08:50 AM revealed Responding to Rapid Response. Patient (Resident) identified with [MEDICAL CONDITION](rapid heart rate) with HR (heart rate) 140, SBP (systolic blood pressure) 110, RR (respiratory rate) 20s-30s; SAT (Saturation) 96%, 100% Fi02 with ambu bagging. Emesis, tube feeding witnessed; lung (+) Rhonchi, R (right) CTA (clear to auscultation) left. CVS([MEDICAL CONDITION] system): [MEDICAL CONDITION].ABD: distended .hypo (hypoactive) bowel sounds; ENT (Ear, Nose, Throat) [MEDICAL CONDITION] BUE (bilateral upper extremities), R (right) > (greater than) L (left). Warm extremities; A/P (Assessment/Plan) : Respiratory Distress, R/O (rule out) aspiration/sepsis. Will send to ER (emergency room ) via (by) 911. A review of the nursing notes revealed the following: May 31, 2015 4:50 AM - Resident is alert and responsive. AM care given, vs (vital signs) 98.4 temperature, P (pulse) 77 R(respirations) 16, BP (blood pressure)127/68, Pulse OX (oximetry) 96%. No evidence of pain noted. Care given will continue to monitor . May 31, 2015 6:30 PM - Resident is alert and responsive, due medications given as ordered. No abnormal findings noted. Vs T 98.2, P 86 R 20, BP 133/78. Pulse Ox 96%. Will continue to monitor. June 1, 2015 4:00 PM - Resident is alert and responsive PM care given. VS (vital signs) T (temperature) 98.6, P (pulse) 87, R (respirations) 20, BP (blood pressure) 130/77 Pulse OX (oximetry) 98%. Turned and repositioned, due meds given. June 2, 2015 5:00 AM - Resident is alert. On vent (ventilator dependent) for support.[MEDICAL CONDITION] and suction care provided. Total care with ADL (Activities of Daily Living). Enteral Feeding in progress. Peg (percutaneous endoscopic gastrostomy) tube patent and flushed well. Will monitor. Vs (BP) 131/72, (P) 76, (R) 18, (T) 98.3. June 2, 2015- 8:35 AM- SBAR (standardized communication in healthcare - S = Situation, B = Background, A = Assessment, R = Recommendation)/Acute change in condition note read: Resident was noted with respiratory distress and an elevated HR (heart rate) of 140 (bpm/beats per minute). Resident was bagged by RT (Respiratory Therapy) while Rapid Response was called. Rapid Response team responded In house officer gave new order to transfer resident via (by) 911 (Emergency). Emesis (vomiting) noted x (times) 1 (one) during bagging with [MEDICAL CONDITION] activity. Resident was then transferred via 911 to (local hospital). Respiratory Therapy Notes: A review of the Respiratory Ventilator Flow Sheet for June 2, 2015 revealed the following: Date: June 2, 2015 Time: 0025 (12:25 AM) Mode: AC Fi02: 40% PEEP: 5 Saturation: 97% Heart Rate: 70 Date: June 2, 2015 Time: 0345 (3:45 AM) Mode: AC Fi02: 40% PEEP 5 Saturation: 98% Heart Rate: 121 Date: June 2, 2015 Time: 08:20 (8:20 AM) Mode: AC Fi02: 40% PEEP: 5 Saturation: 99% Heart Rate (HR): 129 There was no documented evidence that the physician was notified in regards to Resident #5's increased heart rate from June 2, 2015 (3:45 AM) to June 2, 2015 (08:20 AM), which is indicative of approximately 4 hours. A review of the respiratory therapy shift notes revealed: June 2, 2015 (notes beginning June 1, 2015 7PM - 11:59 PM thru June 2, 2015 12 Midnight - 7AM) - 7pm-7am shift note revealed: S: Pt on A/C mode B: Respiratory resident A: Sat 98% HR 71, RR (respiratory rate) 18 BS (breath sounds) Rhonchi/clear, sxn (suction) moderate yellow suction, no distress. R: monitor June 2, 2015 -7AM- 7PM Shift- PT (Patient) transferred to area Hospital. The clinical record lacked evidence that facility staff assessed and monitored Resident #5 when the resident ' s heart rate increased which was first documented on June 2, 2015 at 3:45 AM, heart rate - 121. The resident ' s condition declined as evidenced by increased [MEDICAL CONDITION](rapid heart rate - elevated to 129 beats per minute). A rapid response (a team of health care providers that responds to intervene when a resident shows signs of clinical deterioration to prevent respiratory of [MEDICAL CONDITION]) was called and the resident was subsequently transferred to the emergency room via 911 (Emergency Medical Services) according to the SBAR at the time of transport the resident's heart rate was 140. A face-to-face interview was conducted on September 21, 2015 at approximately 10:30 AM with Employees #18 and #47. Employee #18 stated that his/her shift was 7:00AM to 7:00PM. Employee #18 also stated, when he/she first saw the resident with the heart rate 129 is when the rapid response was called at approximately 8:20AM, the resident vomited when he/she was bagged (manually resuscitated using a bag valve mask). Employee #47 stated when he/she was conducting rounds from the rooms assigned when he/she was called to the rapid response by Employee #18 who stated that the rapid response (team) took over, and that the resident had vomited when he/she was bagged and then the resident was sent out 911 with a heart rate at 140. The night shift nurse was not available for interview. The record was reviewed September 21, 2015. 4. Facility staff failed to accurately assess the respiratory status of Resident #98 who required ventilator services. The facility policy dated May 15, 2015, titled ' Ventilator Management and Nursing Care Respiratory Education ' detailed the following information: care of the [MEDICAL CONDITION], modes of ventilation, alarms and common causes, breath sounds assessment, weaning, and patient suctioning. (This document was provided to the State Agency on September 22, 2015 by the Facility Administrator (Employee #1). The policy entitled, ' Ventilator Settings Definitions ' (no initiated or revised date) included the following information: Mode: The way a breath is delivered, Assist Control: A/C, Synchronized Intermittent Ventilation: SIMV, Continuous Positive Airway Pressure [MEDICAL CONDITION] Rate: (bpm- breath per minute), usually set at 8-12 breaths per minute, Tidal Volume: The amount of volume inhaled in the lungs. The ventilator delivers a pre-set volume of gas with each breath, Fi02: fraction of inspired oxygen (percent of oxygen a patient is inhaling), and Positive End Expiratory Pressure (PEEP): Special setting on the ventilator that keeps the lungs expanded to help get oxygen from the lungs into the bloodstream. (This policy was provided to the State Agency on September 22, 2015 by the Nurse Educator). The facility policy #CP.603, last revised June 17, 2015, titled, ' Ventilator Weaning Protocol ' stipulates, II. Policy: Protocol will be applied per physician ' s written order of Wean per protocol. On September 21, 2015 at approximately 9:30 AM, a review of the admission record revealed that Resident #98 was admitted on [DATE] to the facility with a [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. A physician's orders [REDACTED]. (Defined by the National Institutes of Health as the gradual withdrawal of ventilatory support through utilization of a variety of ventilator modes, periods of total spontaneous ventilation, and appropriate rest periods for muscle unloading (Respiratory therapy was responsible for initiating weaning). <http://clinicalcenter.nih.gov/ccmd/cctrcs/pdf_docs/Ventilator%20Management/02-Ventilator%20Weaning.pdf>) On September 21, 2015 at approximately 9:40 AM, an observation of the ventilator settings for Patient #98 was noted as follows: A/C, Rate 12 VT 500 Fi02 40% PEEP 5 On September 21, 2015 at approximately 9:42 AM, a review of the 'Ventilator Flow Sheet' completed by respiratory therapy (who adjusted the ventilator settings as per weaning protocol) during the period of September 1, 2015 to September 21, 2015 revealed the following documented ventilator settings: A/C Rate - 12 VT - 500 Fi02 - 40% PEEP - 5 Review of the Nursing Respiratory Flow sheet revealed the following recorded ventilator settings for the period of September 1, 2015 to September 21, 2015: A/C Rate - 10 VT - 500 Fi02 - 30% PEEP - 5 The documented assessment of ventilator settings recorded by the nursing staff on September 21, 2015 failed to correlate with the actual settings that reflected the respiratory status of the resident, as observed. Additionally, from September 1, 2015 to September 21, 2015, the documented assessment of ventilator settings recorded by the nursing staff failed to correlate with the actual settings documented by the respiratory therapist. On September 21, 2015 at approximately 9:45 AM, a face-to-face interview was conducted with Employee #16, the registered nurse who was assigned to care for Resident #98. Employee #16 also confirmed that his/her assignment included the care of Residents #37, 98, 111, 134, 137, 138, who were all ventilator dependent. He/she was interviewed at the bedside of Resident #98, at the site of the ventilator. Employee #16 was asked to observe Resident #98 and the ventilator, confirm the ventilator settings, and describe the mode, the set rate, the resident's rate, and the resident's response to the ventilator. Employee #16 stated the rate was 12; but could not explain his/her documentation of a rate of 10 and Fi02 30% or describe the remaining requested information related to nursing care for the specialized ventilator services. On September 21, 2015 at approximately 10:30 AM a face-to-face interview was conducted with Employee #22, who was assigned to care for residents requiring ventilator services. Employee #22 was asked to observe Resident #98 and the ventilator, confirm ventilator settings, and describe the mode, the set rate, the resident's rate, and the resident's response to the ventilator. Employee #22 explained the set rate of 12; however, he/she could not further explain the requested information related to nursing care for the specialized ventilator services. On September 21, 2015 at approximately 10:45 AM a face-to-face interview was conducted with Employee #10, the nurse manager for the unit, regarding the aforementioned findings. He/she acknowledged the findings, stating that the respiratory therapy staff would hold an in-service for the nursing staff. The record was reviewed on September 21, 2015.

Based on observations, record review and staff interview for one (1) of 55 sampled residents, it was determined that facility staff failed to ensure the resident received necessary services to maintain good oral hygiene as evidenced by: one (1) resident who was observed with an accumulation of white colored substance on his/her tongue. Resident #104. The findings include: Facility staff failed to assess and identify the need for medical intervention for Resident #104, who had accumulated white colored [MEDICAL CONDITION] on his/her tongue. A review of documentation related to Activities of Daily Living (ADL) performed on behalf of Resident #104 and through staff interview, it was determined that oral care was consistently provided each shift by facility staff. However, there was no evidence that facility staff identified the need for medical intervention to address the white substance on the resident ' s tongue. Following the survyeor's query, the resident was examined by the medical team and subsequently diagnosed with [REDACTED]. According to, The Lippincott Manual of Nursing Practice, Ninth Edition-2010, pp 613, revealed: Conditions of the Mouth and Jaw Candidiasis- Candidiasis is a fungal infection commonly caused by [MEDICAL CONDITION][MEDICATION NAME]. It usually occurs in the mouth . Candidiasis can become a source of systemic dissemination, particularly in high-risk persons, Clinical Manifestations: (1.) Oral discomfort, burning, altered taste, [DIAGNOSES REDACTED], (2) White, raised, painless plaques, loosely adherent, (3) Possible spread to the esophagus with pain on swallowing and chest pain Management: Topical antifungal agents in oral rinses, [MEDICATION NAME], or creams, such as [MEDICATION NAME] or [MEDICATION NAME] . [MEDICATION NAME] for pain ., Nursing Assessment: Assess extent of [MEDICAL CONDITION] and inflammation in mouth . 2. Assess level of pain . Patient Education and Health Maintenance: (2) Instruct high-risk patients about daily oral examination and signs and symptoms to observe (3). Encourage good oral hygiene An observation of the Resident #104 during the survey period revealed the following: On September 10, 2015 at approximately 4:28 PM- Resident #104 ' s tongue was observed completely coated with a white substance. A second attempt was made on September 14, 2015 at approximately 12Noon to visualize Resident #104 ' s oral cavity with Employee #15. A visualization of the resident ' s oral cavity was unsuccessful because the resident rejected the employee ' s attempt to open his/her mouth. This surveyor conveyed to Employee #15 the concern related to the observation of the white substance on the resident ' s tongue. Employee #15 informed the Nurse Practitioner who evaluated the resident and diagnosed him/her with Oral Candidiasis as follows: Nurse Practitioner note dated September 14, 2015 at 4:10 PM read: Asked to evaluate resident with c/o (complaint of) whitish coating on tongue. Resident is bedbound and clamps mouth close (with) difficulty to adequately view oral cavity. Assessment done (with) aid of primary nurse, = whitish coating on tongue. Attempted to clear tongue with mouth care kit (without) any effect on mouth/tongue coating. (No) distress. A (Assessment):- Oral Candidiasis (Thrush). Plan: [MEDICATION NAME] solution 100,000 units/ml. Apply 5 ml (millimeters) to tongue and clean tongue QID (four times a day) (times) 14 days. Reassess for any adverse changes. Facility staff failed to assess and identify the need for medical intervention for Resident #104 whose tongue was observed coated with a white substance. Resident #104 was totally dependent and facility staff must anticipate the resident ' s needs as evidenced by the annual Minimum Data Set (MDS) assessment dated [DATE]. Section B, Hearing, Speech, and Vision was coded that Resident 104 was unable to speak and was rarely/never understood. Under Section C, Cognition, the resident was coded as severely cognitively impaired and never/rarely made decisions, Section I (Active Diagnoses) included: [MEDICAL CONDITION] Disorder, [MEDICAL CONDITIONS], Craniotomy, Dysphagia. Section G (Functional Status) revealed the resident was coded as being totally dependent with one person for physical assist and personal hygiene (how resident maintains personal hygiene, including combing hair, brushing teeth .). physician's order [REDACTED]. A review of clinical documentation (ADL sheets and Treatment Administration Records) for the months of August and September 2015 revealed staff documented that oral care was provided every shift. An interim physician's order [REDACTED].-fungal medication) Oral Suspension 100,000 units per ml. Apply 5 ml (millimeters) to tongue and clean tongue QID (four times a day) (times) 14 days for thrush. A review of the resident ' s CNA (nursing assistant) Charting flow sheets from September 7, 2015 through September 15, 2015 revealed, Personal Hygiene: Resident required one person physical assist to provide all hygiene tasks (oral care included), with no self-performance. The comprehensive care plan updated August 11, 2015 included the following problem: Alteration in ADL (Activities of Daily Living) function (secondary) to [DIAGNOSES REDACTED]. Staff to provide oral, hair and nail care qd (every day) and prn (as needed) . There was no evidence that facility staff provided oral care consistent with the resident's need. A face-to-face interview was conducted with Employees #15 and #17 on September 14th at approximately 1:00 PM. When queried about how the resident ' s mouth care is performed and the frequency, he/she stated; It is done every day, and an oral swab is used and s/he stated there was no white coating on the resident ' s tongue. He/she further stated sometimes white secretions are in his/her mouth but they are suctioned out, and the mouth and tongue is cleaned every shift. The clinical record was reviewed on September 15, 2015.

Based on observation, record review and staff interviews, for Resident #1, it was determined that facility staff failed to consistently re-assess the worsening right and left ischial wounds. The findings include: Resident #1 was a [AGE] year old resident and was admitted to the facility on [DATE]. According to the Minimum Data Set assessment with an assessment reference date of December 30, 2013, Resident #1 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 the admission history and physical examination [REDACTED] " Past history: Patient choked on steak and had [MEDICAL CONDITION] and was admitted to (hospital) where he/she had intubation and ventilation and later trach. Course complicated with [MEDICAL CONDITION]. Later transferred to (facility) and now off vent but [MEDICAL CONDITION] he/she has [MEDICAL CONDITIONS] and now coma .... " The following " Wound and Skin Progress Notes, " which are the weekly wound team ' s assessment of all wound in the facility, were reviewed as follows: For the Left Ischial Wound: February 1, 2014 Redness (first identified) February 6, 2014 Red area 2.0 cm x 2.5 cm February 13, 2014 Redness 1 cm x 1 cm February 20, 2014 5 cm x 5 cm February 27, 2014 4 cm x 2 cm x 0.1 cm with 10% Slough March 5, 2014 4 cm x 2 cm x 0.1 cm with 10% Slough The left ischial wound had gotten worse between February 14, 2014 and February 27, 2014. The nurses ' notes were reviewed from February 14, 2014 through February 27, 2014. There was no evidence in the nurses ' notes that the change in the left ischial wound was identified and re-assessed. A physician's order [REDACTED]. " A physician's order [REDACTED]. Cleanse the Left Ischium with normal saline, pat dry, apply Santyl ointment then cover with [MEDICATION NAME] daily and PRN. " According to the February 2014 Treatment Administration Record, the nurses ' initials were present in the designated boxes that documented that the treatment was administered every shift. According to the November and December 2013, and January, February and March 2014 Treatment Administration Record, the nurses ' initials were present in the designated boxes by the order, " Turn and reposition q 2 hours " that documented that the resident was turned every two (2) hours. Right Ischial Wound February 14, 2014 Excoriation (first identified) February 20, 2014 3 x 2.5 <0.1, 100% [MEDICATION NAME] February 27, 2014 4 x 4 x 0.1, 30% Slough March 5, 2014 4 x 4 x 0.1, 20% Slough The right ischial wound had gotten worse between February 20, 2014 and February 27, 2014. The nurses ' notes from February 20, 2014 through February 27, 2014 were reviewed. There was no evidence in the nurses ' notes that the change in the right ischial wound was identified and re-assessed. A physician's order [REDACTED]. " A physician's order [REDACTED]. Cleanse the Right Ischium with normal saline, pat dry, apply Santyl ointment then cover with [MEDICATION NAME] daily and PRN. " According to the February 2014 Treatment Administration Record, the nurses ' initials were present in the designated boxes that documented that the treatment was administered every shift. Facility staff failed to consistently re-assess the worsening right and left ischial wounds during daily dressing changes and prior to the wound team ' s weekly rounds. The record was reviewed March 14, 2014. A face-to-face interview was conducted with Employee #1 on March 14, 2014 at 2:15 PM. He/she acknowledged that lack of reassessment and documentation of Resident #1 ' s right and left ischial wounds. The record was reviewed March 14, 2014.

A. Based on observations, record reviews, staff and resident interviews, it was determined that facility staff failed to ensure that the resident environment remained as free of accident hazards as is possible and that each resident received adequate supervision and assistance devices to prevent accidents as evidenced by: unsafe practices that were identified in the designated smoking area as follows: a lack of adequate receptacles for the disposal of smoking products; a lack of emergency equipment and method of communication in the event of an emergency; lack of consistent supervision whereas three (3) residents that were observed sitting in the designated smoking area in the absence of supervision and failure to consistently assess and/or implement precautionary measures for eight (8) of nine (9) residents identified as smokers. Residents #7, 30, 31, 44, 58, 60, 78, and 94. The findings include: Facility staff failed to ensure that the facility was free of potential accident hazards as evidenced by unsafe practices identified in the designated smoking area. Policy: The facility ' s Smoking Policy, #6.03-Resident, Effective date March 2013; date reviewed May 2012, stipulates: "I. Purpose: This facility shall establish and maintain safe resident smoking practices for current resident that are smokers. II Policy: "1...Residents who smoke will be educated on designated smoking area ... 4. Ashtrays will be emptied only into designated receptacles. 5. Only facility-approved ashtrays should be used in designated smoking area... 8. Smoking guidelines for residents with independent smoking privileges based on assessment: a. Residents with independent smoking privileges will be permitted to keep cigarettes, pipes, tobacco and safety lighter. b. Residents with independent smoking privileges may not give smoking articles to other residents with restricted smoking privileges. (Note: Anyone who observes this happening will report incident to the charge Nurse immediately.) 9. Smoking guidelines for residents who need to be supervised while smoking: a. Residents without independent smoking privileges may not have or keep any type of smoking articles, including cigarettes, tobacco lighters of any kind or matches in their room. b. Residents without independent smoking privileges must be taken to the designated smoking area with a staff member, family member or volunteer. 10. Safety equipment, such as a fire extinguisher and /or fire blanket, must be assessable to designated smoking areas. 11. Smoking aprons will be provided based on smoking assessment ... 13. This facility will check periodically to determine if residents have any smoking articles in violation of our smoking policies. Staff shall confiscate any such articles, and will notify the Charge Nurse/Unit Manager that they have done so. " Observations: Residents occupying the designated smoking area were observed unsupervised as follows: On July 23, 2013 at approximately 11:30 AM, three (3) residents; Residents #7, 44 and 58 were observed seated in wheelchairs talking amongst one another on the out-of-doors deck. The residents were alone and not accompanied by facility staff. A second observation on July 23, 2013 conducted at approximately 2:50 PM revealed that the residents who occupied the out-of-doors deck were accompanied by a staff person. Signage posted on the door proximal to the out-of-doors deck displayed the universal symbol for "No Smoking " and read "This is a smoke free facility...thanks for not smoking." On July 24, 2013 at approximately 1:00 PM, Residents #7, 44 and 58 were observed smoking cigarettes on the out-of-doors deck. A flat aluminum - like pan was observed on the floor of the deck. The residents occupying the deck identified the pan as an "ashtray". Several (at least 10) cigarette butts were observed scattered along surface of the wooden deck. Multiple burn marks were observed atop and alongside the surfaces of the handrails of the deck whereas it appeared that cigarettes had been smashed for extinguishing. Cigarette butts were observed scattered along the surface of the driveway in front of the out-of-doors deck. The surface of the driveway was covered with an oil-like substance likely derived from parked vehicles (ambulances). Employee #35 accompanied the residents smoking on the deck and was observed sweeping cigarette butts off of the surface of the wooden deck into a dustpan for disposal. In response to a query, Employee #35 identified the out-of-doors deck as the designated smoking area and also identified the area as the ambulance entrance. He/she stated that (his/her) assignment for the day included monitoring the smoking activities on the deck. In response to a query regarding the presence of emergency equipment, such as a fire retardant apron(s); fire extinguisher or emergency communication device; Employee #35 stated that in the event of an emergency, (he/she) would leave the deck to go into the facility to obtain assistance at the security station. Employee #35 acknowledged that there were no emergency supplies proximal to the designated smoking area in the event of an emergency. He/she further stated that (he/she) usually had a cell phone (personal) that could be used to call for assistance. Facility staff failed to ensure that the designated smoking area was equipped with adequate receptacles for the safe disposal of cigarette waste. Additionally, there was no evidence of equipment and/or devices proximal to the designated smoking area to assist in the event of a fire and/or emergency. There was no method of communication proximal to the deck to alert facility staff in the event of an emergency. There was no evidence that facility staff consistently assessed the safe-smoking needs, as stipulated in the policy, for eight (8) of nine (9) residents identified by the facility as smokers, Residents #7, 30, 31, 44, 58, 60, 78, and 94. Additionally, staff failed to implement precautionary measures and/or devices for residents assessed as "requiring supervision while smoking" as follows: The facility' s " Resident Smoking Agreement " stipulates: 1. As a resident in this facility, you will be required to only smoke in the designated smoking areas. 2. You must supply your own smoking supplies. 3. Those Residents that need supervision will be required to keep their smoking supplies at the nurses ' station. 4. You are not permitted to provide other residents who smoke with matches, lighters or cigarettes. 5. You will be assessed for your ability to be safe while smoking on admission, quarterly and when you have a change in condition. 6. You may be required to wear a smoking apron for your safety. A review of the Resident Smoking Agreements in the resident clinical records revealed: The " Resident Smoking Agreement " for Resident #7 revealed " refused to sign the agreement " recorded at the section of the form allotted for resident ' s signature on the assessments dated April 11, 2012 and December 26, 2012. Resident #30 signed the " Resident Smoking Agreement " on July 2, 2012 Resident #31 signed the " Resident Smoking Agreement " on April 11, 2012 Resident #44 signed the " Resident Smoking Agreement " on July 24, 2013 Resident #58 signed the " Resident Smoking Agreement " on February 13, 2013 Resident #60 did not have a signed " Resident Smoking Agreement " as of July 24, 2013 Resident #78 signed the " Resident Smoking Agreement " on April 14, 2012 Resident #94 signed the " Resident Smoking Agreement " on April 17, 2012 Resident record reveiws and interviews revealed: According to the " Smoking Assessment " for Resident #7 completed on October 12, 2012 and December 26, 2012 the resident was identified as a smoker, required supervision, and a smoking apron. A face-to-face interview was conducted with the Resident on July 24, 2013 at approximately 6:05 PM. He/she stated, " I smoke by myself. I don ' t need no one to smoke. " According to the Smoking Assessment for Resident #30 completed on January 14, 2013 and April 10, 2013 the resident was identified as a smoker, required supervision, and a smoking apron. According to the Smoking Assessment for Resident #31 completed on November 2, 2012 the resident was identified as a smoker, required supervision, and a smoking apron. The " At Risk for injury from burn while smoking " care plan for Resident # ' 31 was last updated on March 12, 2013. A face-to-face interview was conducted with the Resident on July 24, 2013 at approximately 6:10 PM. He/she stated, " I am grown no one needs to watch me go out to smoke. We (other residents) go out together and smoke. " Resident #44 did not have a " Smoking Assessment " or a care plan to address the resident ' s safely while smoking. According to the " Smoking Assessment " for Resident #58 completed on February 13, 2013 and May 7, 2013 the resident was identified as a smoker, required supervision, and a smoking apron. A face-to-face interview was conducted with the Resident on July 24, 2013 at approximately 6:15 PM. He/she stated that he/she smokes and buys own cigarettes. On July 25, 2013 at approximately 11:00 AM, Resident #58 queried the SA representative as to why they were no longer able to smoke on the deck. He/she further stated they have smoked on the deck for many years and never had anybody watching them. " We ' re grown and don ' t need no baby sitters. " Resident #60 did not have a " Smoking Assessment " or a care plan to address the resident ' s safely while smoking. A face-to-face interview was conducted with the Resident on July 24, 2013 at approximately 6:15 PM. He/she stated that he/she smokes and buys own cigarettes. According to the Smoking Assessment for Resident #78 completed on October 9, 2012 and January 3, 2013 the resident was identified as a smoker, required supervision, and a smoking apron. According to the Smoking Assessment for Resident #94 completed on September 24, 2012 and March 13, 2013 the resident was identified as a smoker, required supervision, and a smoking apron. There was no care plan initiated to address Resident #94 ' s smoking. On July 24, 2013 at 6:00 PM, cigarettes were observed in the top drawer of the resident ' s night stand. Additionally, during an interview with Resident #94 on July 23, 2013 at 3:49 PM a package of cigarettes was observed in the top draw of his/her nightstand. There was no evidence that Residents ' #7, 30, 78, and 94 were assessed for their needs as it relates to safety while smoking on a quarterly basis as stipulated in the facility ' s smoking policy. Resident ' s #44 and 58 were identified as smokers by the facility, however there was no Resident Smoking Assessment initiated. Staff Interviews A face-to-face interview was conducted with Employee #2 on July 24, 2013 at approximately 4:45 PM. He/she stated, "The area that they smoke in is not the safest area due to the trucks and ambulances. Most of the residents we have will be unsupervised (when smoking, based on the assessment). We let them keep their cigarettes. The smokers get evaluated quarterly. Smoking aprons are on the unit. Most residents refuse to wear them. We don ' t have a list for staff members that come down to supervise the resident ' s when they smoke. Each unit will designate a person. We have not been keeping the names of the staff that come down to supervise the residents." An observation of the designated smoking area was conducted in the presence of Employee #2. At this time Employee #2 acknowledged that there was no emergency equipment or method of communication to use in the event of an emergency. A tour of the nursing units was conducted in the presence of Employee #2 in search of the smoking aprons. Two (2) smoking aprons were observed unused, in the original packaging, in a drawer on the fourth floor, in the nurse charting area. A face-to-face interview was conducted with Employees #2, 3 and 7 on July 24, 2013 at approximately 5:00 PM. It was stated that there was no smoking assessment, agreement or smoking care plan for Resident #44. Additionally it was acknowledged that the smoking agreements, assessments and/or the care plans were not updated or completed for Residents # 31, 60, 69, and 94. A face-to-face interview was conducted with Employee #1 on July 24, 2013 at approximately 6:30 PM. He/she stated acknowledged the findings in designated smoking area at the time of the observation. Smoking Schedule A review of the "Smoking Schedule" revealed the following times for residents to smoke: 10:00 AM - 4th floor 12:00 Noon - 5th floor 2:00 PM - 6th floor 4:00 PM- 4th floor 6:00 PM- 5th floor A face-to-face interview was conducted with Employee #2 on July 24, 2013 at 6:21 PM. He/she stated, "Each unit will designate an employee to go to the smoking area with the resident. We have not been keeping the names of the employees, we don't write the names down, and we don't have a designated list of employees (for the smoking area). The staff stay (in the smoking area) until the residents are finished smoking." There was no evidence that facility staff consistently supervised the residents outside in the designated smoking area. Smokers List A review of the listing provided by Employee #2 (no date indentified on the listing) revealed that the facility identified six (6) residents that engaged in smoking activities, however; nine (9) residents were identified as per a review of each of the residential/clinical units. The facility ' s " Smoker List " lacked evidence of a differentiation between those residents that were assessed as independent smokers vs. those that required supervision. There was no evidence that the facility ' s " Smokers " list was inclusive of each of the residents identified by the facility as a smoker. In Summary Facility staff failed to consistently monitor residents occupying the out-of-doors deck and designated smoking area. Residents were observed occupying the out-of-doors deck without supervision. There was no evidence that the facility consistently assigned staff to monitor the activities on the out-of-doors deck. The receptacle (aluminum pan) utilized for the disposal of cigarette waste failed to meet safe disposal requirements and was inadequate in number. Cigarette butts were observed scattered along the wooden surface of the deck, wooden railings had burn marks and the driveway with an oil-like substance on its surface was scattered with cigarette butts, posing a potential fire hazard. There was no evidence of equipment proximal to the designated smoking area and/or a method of communication to assist in case of fire or the event of an emergency (such as a fire retardant apron/blanket; fire extinguisher; first aid equipment, walkie-talkie etc.) There was no evidence that resident ' s who engage in smoking activities were consistently assessed for safe smoking needs by way of smoking assessments and/or care plans. Facility staff failed to implement precautionary methods (e.g. burn retardant aprons) as stipulated by the care plans of resident ' s engaged in smoking activities. Facility staff failed to ensure that the facility was free of potential accident hazards as evidenced by unsafe practices identified in the designated smoking area. The facility Administrator was notified regarding the immediate concerns and potential accident hazards associated with the lack of supervision and unsafe smoking practices on the out-of-doors deck. An Immediate Jeopardy was identified by the Department of Health at 7:30 PM on July 24, 2013 with a scope and severity of " IJ-K. " On July 24, 2013, the facility Administrator developed a corrective action plan and implemented measures to monitor residents who desired to occupy the out-of-doors deck. Smoking was prohibited on the deck until an ample supply of acceptable receptacles for the safe disposal of smoking waste was obtained. A plan was proposed to escort residents to an alternate area outside of the facility to engage in supervised smoking. Facility staff were re-educated on the facility ' s smoking policy, an emergency cart with burn retardant aprons and first aid supplies was developed and placed proximal to the designated smoking area. A two-way communication device (radio) was provided for the staff assigned to supervise the residents in the smoking area as a source of communication. On July 25, 2013, a Fire Inspector from the District of Columbia Fire Department conducted an assessment of the areas of concern. The corrective action plan provided by the facility Administrator included but was not limited to the aforementioned measures and was accepted in collaboration with the D.C. Fire Inspector. The IJ was lifted on July 25, 2013 at 6:23 PM. The scope and severity was lowered to a level "E. " B. Based on observations, record reviews, staff and resident interviews, it was determined that facility staff failed to ensure that the resident environment remained as free of accident hazards as is possible as evidenced by: hot water temperatures that exceeded acceptable ranges in 10 of 24 resident rooms; Heating, Ventilation and Cooling (HVAC) units in two (2) of 117 resident rooms that emitted smoke and fumes when turned to the " on" position and sixteen (16) of 117 HVAC units in resident rooms that failed to deliver cool air when activated; an oxygen tank that was observed insecurely attached to the rear of one (1) residents wheelchair and staff that failed to use the appropriate type of scissors for bandage removal for one (1) resident. Residents #95 and 105. The findings include: 1. Facility staff failed to ensure that hot water temperatures were maintained in acceptable ranges as to not pose a burn hazard in 10 of 24 resident rooms observed. On July 30, 2013 at approximately 10:45 AM the water temperatures at the faucets in resident rooms exceeded acceptable ranges as follows: Room #4157 -129 degrees Fahrenheit (F) Room #4155 -119 degrees F Room #4147 -128 degrees F Room #5157-135 degrees F Room #5155-132 degrees F Room #5149-125 degrees F Room #5119-123 degrees F Room #5111-119 degrees F Room # 5105-121degrees F Room # 6110-130 degrees F A face-to-face interview was conducted with Employee #10 at the time of the observations (July 30, 2013 at 11:30 AM). He/she stated, " We have adjusted the water temperatures. We will recheck the temperatures in the rooms with the elevated water temperatures, and check more rooms to monitor the temperatures. We have not had any complaints of the water being too high. We test AM and PM water temperatures in the resident rooms every day. " At the time of the observations, face-to-face interviews were conducted with the residents that occupied the rooms with elevated water temperatures, 4147, 4155, 5111 and 5157 and no concerns were verbalized regarding water temperatures. Following the adjustment of water temperatures by facility staff, a secondary review of the rooms whose water temperatures exceeded acceptable parameters were assessed and found to be within acceptable range. The facility ' s record of hot water temperatures were reviewed for the period of June 1, 2013 to July 30, 2013. The data was recorded on the facility ' s form " Hot Water and Room Temperature Logs. " It was noted that water temperatures in resident rooms were not in acceptable parameters on 10 occasions. Employee #10 who was present at the time of the review, on July 30, 2013 at approximately 11:41 AM, stated that the necessary adjustments were made to address the water temperatures that were elevated. There were no residents that sustained injury secondary to the elevated water temperatures. Facility staff failed to ensure that hot water temperatures were maintained in acceptable ranges as to not pose a burn hazard to the residents in the facility. The temperatures were subsequently adjusted and met acceptable ranges. 2. Facility staff failed to ensure that electrical equipment was in safe operating condition as evidenced by Heating, Ventilation and Cooling (HVAC) units in two (2) of 117 resident rooms that emitted smoked and fumes when activated. This incident presented a potential smoke hazard to residents. Additionally, 16 of 117 HVAC units failed to deliver cool air when activated as follows: a. During an environmental tour of the facility on July 29, 2013 at 10:30 AM in the presence of Employee #10, it was determined that the HVAC unit in room #4112 failed to function as intended. Employee #10 activated the cooling unit by turning the switch to the " on " position and the temperature control to the coolest setting. Moments after the unit was activated, smoke was observed coming from the unit. Employee #10 immediately turned the switch to the " off " position and advised nursing staff to remove the resident from the room. Subsequently, smoke-like fumes emitted from the HVAC unit. Employee #10 immediately advised the maintenance staff to dismantle the unit to determine the cause of the malfunction. He/she subsequently reported that the motor required repair and that measures were implemented immediately to resolve the issue. b. An observation of the HVAC system in room 5155 on July 20, 2013 at approximately 11:00 AM revealed that the cooling system failed to function as intended. Employee #40 activated the HVAC system by turning the dial to the " on " position. The HVAC unit emitted smoke and fumes and the system was immediately turned off. Measures were implemented to identify the cause and to repair the malfunction. A subsequent observation of the HVAC unit on July 29, 2013 revealed that the unit was repaired and observed functional. c. Seven (7) of 39 HVAC units observed on the 4th floor failed to deliver cool air when the equipment was turned " on " and the temperature control turned to the " coolest " setting in the following rooms: 4104; 4116, 4118, 4119, 41 23, 4129 and 4130. The observations were made on July 29, 2013 at approximately 11:00 AM in the presence of Employee #10. Six (6) of 39 HVAC units observed on the 5th floor failed to deliver cool air when the equipment was turned " on " in the following rooms: 5157, 5144, 5123, 5116, 5111 and 5110. The observations were made on July 29, 2013 at approximately 11:15 AM in the presence of Employee #40. Three (3) of 39 HVAC units observed on the 6th floor failed to deliver cool air and/or lacked knobs to turn the equipment " on " in the following rooms: 6143, 6144 and 6155. The observations were made on July 29, 2013 at approximately 11:20 AM in the presence of Employee #43. 3. Facility staff failed to ensure Resident #95 was free of accident hazards as evidenced by an oxygen cylinder that was not secured during transport. On July 24, 2013 at approximately 5:05 PM, Resident #105 was observed sitting in the common area of the facility ' s front lobby across from the information desk. Resident ' s oxygen cylinder was hanging freely and was attached to a hook hanger on resident ' s wheelchair. The oxygen cylinder was not secured. When queried, " Who escorted him/her down and who attached the oxygen cylinder to the wheelchair? " He/she responded; I come down to the lobby just to get off the floor. The therapist placed the oxygen on the chair for me. " A face-to-face interview was conducted with Employees #15 and #23. Employee #23 acknowledged that he/she attached the oxygen cylinder to the back of the wheelchair. Both acknowledged the aforementioned observation and stated the oxygen cylinder should have been secured prior to the resident leaving the unit. Facility staff failed to ensure that the oxygen cylinder was secured as to prevent accidents. The observation was made on July 24, 2013. 4. Facility staff failed to ensure that Resident #105 remained free of potential accident hazards during a wound treatment as evidenced by the observation of the licensed nurse failing to use blunt or safety edged scissors to cut away gauze dressing that covered the resident ' s lower extremity wound. During a dressing change observation on July 31, 2013 at approximately 3:15 PM, Employee #8 was observed removing the gauze dressing from Resident #105 ' s lower extremities with " straight edged " scissors (regular scissors with pointed edge) that posed a potential to incise skin when placed in proximity during the cutting motion. A face-to-face interview was conducted with Employee #8 on July 31, 2013 at approximately 4:00 PM regarding the aforementioned observation. He/she acknowledged that straight edged scissors were used instead of bandage scissors. The observation was made on July 31, 2013. Facility staff failed to ensure that Resident #105 was free of potential accident hazards as evidenced by a failure of licensed staff to use the appropriate scissors for the removal of wound dressing gauze.

1. Based on record review and staff interview for one (1) of 43 sampled residents, it was determined that the facility failed to assess and monitor an alteration in consciousness that subsequently lead to hospitalization . Resident #166 The findings include: Facility staff failed to consistently monitor and act with timeliness when it was determined Resident #166 sustained an alteration in the level of consciousness. Through interview, it was stated that the resident exhibited signs and symptoms inconsistent with his/her normal level of consciousness (sleeping most of the day). There was no documented evidence that facility staff acted to address the resident ' s status as it relates to level of consciousness during the course of the day shift (approximately seven hours). There was no evidence of a neurologic assessment and/or notification of the medical team regarding the resident ' s change in level of consciousness. Each of the staff interviewed, that were assigned to Resident #166 for the day shift on September 28, 2013 verbalized an account of awareness that the resident was excessively drowsy. Interviews Through face-to-face interview with facility staff, it was determined that Resident #166 sustained an alteration of consciousness on September 28, 2013 as follows: A. A face-to-face interview was conducted with Employee #15 on October 18, 2013 at approximately 3:00 PM. He/she stated, " I provided care to (Resident #166) on that day (September 28, 2013). On this particular day the (resident) was not (his/her) usual self ...very sleepy. (Resident) is usually alert, nods head, blinks eyes and moves (his/her) body to communicate (resident is non-verbal) ...I talk with (him/her) in our language, (he/she) likes that ... we ' re from the same country. The (family member named) was crying because the (resident) was not his/her usual self, I told the nurse that morning. " According to Employee #15 ' s written statement (signed and dated on October 18, 2013), " On 9/28/2013 ... I made rounds that morning and found (Resident #166) asleep. Later went into the room about 11:00AM ... and found (resident) not (his /her) usual self. ...Notified the nurse and respiratory ... " . B. Through interview with Employee #12 on October 18, 2013 at 8:30 AM, Employee #12 stated that while conducting rounds in preparation for change-of-shift, at approximately 2:30 PM on September 28, 2013, assessed the resident in response to concerns verbalized by the next of kin, who was present at the bedside, that the resident had been sleeping most of the day. On (Employee #12 ' s) assessment, the resident was alert, awake with no respiratory distress noted. Employee #12 informed the nursing supervisor, who was walking past the corridor near Resident #166 ' s room, regarding the concern verbalized by Resident #166 ' s next of kin as it relates to excessive sleepiness. C. A face-to-face interview was conducted with Employee #14 on October 18, 2013 at approximately 4:00 PM. He/she stated, " The vent was checked three times (during the day shift on 9/28/2013, 7AM- 3PM) by a respiratory therapist. At each time (Resident #166) was suctioned with no respiratory distress. (Resident named) was not (his/her) usual self, (he/she) was very drowsy but arousable. Physician order [REDACTED]. Physician telephone order dated 9/28/2013 at 6:30PM (6:30)PM, Start IV (intravenous), given 2 Liter of NS (normal saline) Bolus, recheck B/P (blood pressure) after fluids are completed " . Nursing Notes A. The following nurse ' s entry was recorded for the day shift on September 28, 2013: " 9/28/13 2:30 PM vent (ventilator) dependent, T/C ([MEDICAL CONDITION] collar) intact and patent.[MEDICAL CONDITION] provided. Total care provided. Medicated as ordered. H20 flushes administered as [DEVICE] is patent. Aspiration precautions maintained. TARP Q2 (turned and repositioned every two hours) maintained. No respiratory distress noted. V/S (vital signs), 130/76 (blood pressure - b/p); 70 (pulse - P); 20 (respirations - R); 98.1 (temperature - T). " B. A review of a nursing note dated October 11 (year not recorded) at 4PM revealed, " Change in Condition " nurse ' s notes (nurse assigned to resident during the evening shift): " Late entry for 9/28/13 at 8PM. Resident was noted with low b/p (blood pressure) of 70/34. (Dr named) was notified and (he/she) ordered to give 2 liters Bolus (intravenous fluids (IVF)). IV was initiated and IV fluids were given. B/P increased to 101/47, (pulse) 92, (respirations) 20, (temperature) 98.9. Resident started having labored respirations. (doctor named) notified and new order given to transfer resident to the ER (emergency department) via 911 EMS and stretcher. Resident was then transferred to (hospital named) at 8:10 PM ... " (as taken from facility documentation). The resident ' s level of consciousness as recorded by the District of Columbia Fire and Emergency Services (EMS) team that responded to the 911 call on September 28, 2013 was as follows: EMS arrived at the facility at 6:50 PM. The chief complaint " unconscious " and symptoms " low blood pressure. " LOC (level of consciousness) orientation, " unable to assess -unresponsive ....upon first contact the patient was noted to be semiconscious ... " The resident ' s vital signs at 1910 (7:10 PM) as recorded by EMS: blood pressure 86/42; pulse 97 and respirations 23. According to hospital records, the resident was hospitalized on [DATE] after receiving treatment in the Emergency Department. A review of the " Hospital Course " dated October 13, 2013 and electronically signed by the physician, revealed Resident #166 presented to the hospital with " AMS " (Altered mental status). 2. Based on record review and staff interview for one (1) of 43 sampled residents, it was determined that the facility failed to consistently assess and monitor Resident #166 for potential complications associated with the use of an indwelling urinary catheter. The resident was subsequently transferred to the hospital. The findings include: Facility staff failed to consistently assess and monitor Resident #166 ' s urinary status. The resident was assessed with [REDACTED]. Several hours of the shift lapsed (approximately 7 hours) before the resident ' s urinary status was assessed. The assessment was not initiated until licensed staff conducted rounds in preparation for shift change (day to evening shift). Nurses Notes The clinical record lacked evidence that staff consistently assessed and recorded an account of Resident #166 ' s fluid balance as it relates to the amount of fluids that the resident consumed in contrast to the amount eliminated (intake and output). The most recent documentation related to the resident ' s urinary output was on September 27, 2013 at 6AM as follows: Nurse ' s entry September 27, 2013 6AM read: " ...foley cath (indwelling catheter) draining clear amber urine. 250cc output ... " There was no evidence that staff assessed the resident ' s urinary output during the course of the shift (7AM - 3PM) on September 28, 2013, with the exception of the assessment conducted in preparation for change of shift at 2:30 PM. The designated intake and output flow sheet was blank for the month of September 2013. Medication/Treatment Administration Record A review of the Medication/Treatment Administration Record for the month of September 2013 revealed that the resident received hydration and nutrition enterally (via feeding tube). The enteral orders were as follows: "[MEDICATION NAME] (enteral formula - nutritional product) at 65 cc for 18 hours via PEG (Percutaneous endoscopic Gastrostomy) " . (No date recorded noting when the order started.) 225 ml H20 (water) flush Q (every) 6 hours via Peg X 24 hours or until 900 ml is delivered. Dx. Hydration Flush Peg with 25 ml of water before and after medication pass physician's order [REDACTED]. physician's order [REDACTED]. Dx. Hydration. " Interviews Employee #12 stated that while conducting rounds in preparation for change-of-shift, at approximately 2:30 PM on September 28, 2013 assessed the resident in response to concerns verbalized by the next of kin, who was present at the bedside, that the resident had been sleeping most of the day. On (Employee #12 ' s) assessment, the resident was alert, awake with no respiratory distress noted. Employee #12 informed the nursing supervisor, who was walking past the corridor near Resident #166 ' s room, regarding the concern verbalized by Resident #166 ' s next of kin as it relates to excessive sleepiness. The nursing supervisor (Employee #13) initiated an assessment and it was determined that the resident ' s abdomen was distended and the indwelling urinary catheter drainage bag had very little urine in it, " approximately 20 cc " (representative of urinary elimination for the entire 7AM - 3PM shift). The supervisor deflated and removed the urinary catheter; the resident voided onto the incontinent brief he/she was lying atop. He/she reinserted the new indwelling catheter and approximately 600 cc of urine was eliminated into the drainage bag. Hospital Assessment According to hospital records, the resident was hospitalized on [DATE] after receiving treatment in the Emergency Department. A review of the " Hospital Course " dated October 13, 2013, revealed the resident ' s admitting [DIAGNOSES REDACTED]. " 3. Based on record review and staff interview for one (1) of 43 sampled residents, it was determined that the facility failed to perform laboratory tests in accordance with physician's order [REDACTED]. The findings include: Facility staff failed to consistently manage Resident #166 ' s anticoagulation therapy in accordance with physician's order [REDACTED]. Record review physician's order [REDACTED]. (diagnosis) [MEDICATION NAME] usage " . Physician orders [REDACTED]. Physician orders [REDACTED]. physician's order [REDACTED]. No PT/INR 9/23/13 and continue every Monday and Thursday. " physician's order [REDACTED]. Laboratory results Laboratory result dated 9/20/2013 PT 13.6 sec. (seconds) (reference range 11.8-14.5 sec) INR 1.1 (reference range 0.8 - 1.2) Laboratory result dated 9/24/2013 PT 116.0 sec. (reference range 11.8-14.5 sec) " H " (high) INR 1.3 (reference range 0.8 - 1.2) " H " (high) Record lacked a laboratory report of PT/INR for 9/26/2013 (Thursday) as per physician order. Nursing notes A nurse ' s note dated September 26, 2013 (Thursday) at 3:00 PM read: " ...PT/INR was done this AM, awaiting result at this time ... " The clinical record lacked evidence of PT/INR results for September 26, 2013. Interview The lack of a PT/INR blood test for September 26, 2013 was confirmed during a telephone interview with Employee #2 on October 30, 2013. He/she stated " there are no results for a PT/INR done on September 26, 2013; He/she acknowledged the nurse ' s note indicated that the test was done. " District of Columbia Fire and Emergency Medical Services (DCFEMS) A review of the District of Columbia Fire and Emergency Medical Services (DCFEMS) records revealed that the EMS team arrived at the facility in response to the 911 call at " 1850 " (6:50 PM). A review of the care events summary revealed " ...patient was warm and dry to touch but was noted to have blood in (his/her) urine cath (catheter) bag) ... " Hospital Records According to hospital records, the resident was hospitalized on [DATE] after receiving treatment in the Emergency Department on September 28, 2013. A review of the " Hospital Course " dated October 13, 2013 and electronically signed by the physician, revealed Resident #166 had an " elevated INR on admission. "The resident ' s PT/INR level of 79.0 and 10.2 respectively, was assessed at a " critical range " (any test result that may require rapid clinical attention to avert significant patient morbidity or mortality ...normal range: PT - 11.8-14.5 and INR 0.8 - 1.2; in anticoagulant use, an INR of 2.0-3.0 is considered acceptable, however variable depending on the indication of use, reference: <http://www.suc.org.uy/emcc2012/Anticoagulantes/2_OralAnticoagulantTherapy.pdf>). The resident required the administration of plasma [MEDICAL CONDITION] to reverse the elevated anticoagulation effects. A review of records revealed staff failed to obtain a monitoring PT/INR blood sample on September 26, 2013 as prescribed. Approximately 72 hours later, the resident was assessed with [REDACTED]. Blood was noted in the resident's urine according to the DCFEMS documentation on September 28, 2013. Plasma transfusion was required upon initial assessment on September 28, 2013, as documented in Hospital Course dated October 13, 2013. Relevant documentation in the clinical record for Resident #166 revealed the following: According to the admission Minimum Data Set (MDS) dated [DATE], Resident #166 was admitted to the facility July 29, 2013 and his/her [DIAGNOSES REDACTED]. According to Section B, Hearing, Speech and Vision, Resident #166 was coded with unclear speech (slurred or mumbled words); however, the resident was able to understand others and was able to make self understood. Under Section K, Nutrition, the resident was coded as receiving nutrition and hydration via feeding tube. Section G, Functional Status revealed the resident was totally dependent for functional mobility and activities of daily living. The findings were reviewed with Employee #2 on October 10, 2013 at 2:55 PM and again on October 30, 2013 at 1:30 PM. 4. Based on record review and staff interview for one (1) of 43 sampled residents, it was determined that facility staff failed to perform a laboratory test in accordance with physician's order [REDACTED]. A review of the clinical record for Resident #94 revealed the resident ' s medication regimen included [MEDICATION NAME] ([MEDICATION NAME]) 300mg daily, an anticonvulsant medication for the management of a [DIAGNOSES REDACTED]. A progress note documented by the nurse practitioner (NP) on September 5, 2013 revealed that the resident ' s [MEDICATION NAME] blood level was sub-therapeutic (below the dosage level used to treat a disease) at 6.8 mcg/ml (reference range: 10-20 mcg/ml) as follows: " 9/5/13 3PM; NP note, Labs (9/4/13) [MEDICATION NAME] 6.8 ...no [MEDICAL CONDITION] activity [MEDICAL CONDITION] disorder with subtherapeutic [MEDICATION NAME] level ...bolus [MEDICATION NAME] 300mg po x1 (once by mouth) today, repeat lab in 7-10 days. " A review of the physician ' s " Interim Order " signed by the NP on September 5, 2013 directed, " 1) Extra dose of [MEDICATION NAME] 300 mg po (by mouth) (x1) today for [MEDICATION NAME] level 6.8; [MEDICATION NAME] level on 9/13/13 AM. " Resident #94 ' s clinical record lacked documented evidence that a [MEDICATION NAME] level was obtained on September 13, 2013 as prescribed. A face-to-face interview was conducted with Employee #15 on October 9, 2013 at 4:11PM. He/she stated, " I reviewed the record and called the lab. It ([MEDICATION NAME] level) was not done. " There was no evidence that facility staff obtained the [MEDICATION NAME] level for Resident #94 as ordered. The clinical record lacked evidence that the resident sustained [REDACTED].

Based on observations, record review, staff interview for five (5) of 54 sampled residents, it was determined that facility staff failed to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care as evidenced by a failure to: act with timeliness to obtain a prescribed vascular consultation and ensure positioning during an enteral feeding consistent with physician's order [REDACTED]. Residents' #105, 81,126, 143 and 145. The findings include: 1(a) Facility staff failed to act with timeliness on an order for [REDACTED]. Subsequently, the resident ' s vascular system progressively declined and three (3) new wounds were assessed on [DATE]. According to an " History and Physical " dated [DATE] Resident #105 ' s medical [DIAGNOSES REDACTED]. " An interim physician's order [REDACTED]. " The record revealed the arterial Doppler was performed on [DATE]. Following the report of the arterial Doppler, the following order was noted: physician's order [REDACTED]. (Send resident with arterial Doppler study report done on [DATE]). " Physician ' s interim order dated [DATE] at 4:00 PM directed: " Droplet Isolation for " + " Multi-drug resistant AcretobacterBaumannii tracheiotis. " Physician ' s interim order dated [DATE] at 6:10 PM- " Discontinue vascular surgery consults. " A radiology report dated [DATE] revealed the following: " Procedure: Arterial Duplex Doppler- Lower Extremities- Impression: No blood flow involving right proximal middle and distal superficial femoral arteries; No blood flow involving left proximal and middle superficial femoral arteries; Unable to get blood flow in anterior tibia, and dorsal is pedis arteries laterally. Mild to moderate [MEDICAL CONDITION] disease involving multiple ribs, arteries as mentioned above, right greater than left. " According to the quarterly MDS (Minimum Data Set) with an ARD (Assessment Reference Date of [DATE] revealed that Resident #105 was coded in Section M (Skin Conditions) was coded as having two (2) venous and arterial ulcers present. The admission MDS with an ARD date of [DATE] revealed that Resident #105 was coded in Section M (Skin Conditions) as having " 0 " venous and arterial ulcers present. The " Wound and Skin Care Progress Note " sheets, revealed the following: " [DATE]- Onset- [DATE]- Location- Right heel- Stage/Etiology- DTI (Deep Tissue Injury) - 7.0 x 9.0 x UTD (Undetermined Depth) [DATE]- Right heel- Location: Right Heel; Stage- DTI; 7.0 x 9.0 x UTD [DATE]- Right heel- DTI; 7.0 x 7.0 x UTD [DATE]- Right heel; Stage III- 7.00 x 7.0 x 0.1 [DATE]- Right heel; Stage III- 6.0 cm x 7.0 x 0.2 [DATE]- Right heel; Stage III- 6.0 x 6.0 x 0.2 [DATE]- Right heel; Stage III- 6.5 x 5.0 x 0.2 [DATE]-Right heel; Stage- Full thickness vascular wound- 6.0 x 7.0 x 0.1 [DATE]- Right heel; Stage- Full thickness vascular wound- 6.5 x 8.0 x <0.1 [DATE]- Right heel; Stage- Full thickness vascular wound- 7.0 x 6.0 x <0.1 (vascular referral pending [DATE]- Right heel; Stage- Full thickness vascular wound- 3.0 x 2.0 x <0.1- vascular referral pending [DATE]- Right heel; Stage- Full thickness vascular wound- 3.0 x 3.0 x <0.1- vascular referral pending [DATE]- Right heel; Stage-Full thickness vascular wound- 5.5 x 6.0 x <0.1- vascular referral pending [DATE]- Right heel- Stage-Full thickness vascular wound- vascular referral pending [DATE]- Right heel-Stage-Full thickness vascular wound- 4.0 x 3.0 x <0.1- vascular referral pending [DATE]- Right heel- Stage- Full thickness vascular wound- 2.0 x 3.0 x <0.1- vascular referral pending [DATE]- Right heel- Stage- Healing full thickness vascular wound- 1.0 x 2.0 x <0.1- vascular referral pending [DATE]- Right heel- Stage: Full thickness vascular wound- 5.0 x 4.5 x UD-vascular referral is pending. [DATE]- New onset-Left heel-Stage- Full thickness vascular wound- 7.5 x 8.5cm x UD- no drainage- vascular referral ending [DATE]- New onset- Left plantar distal foot- Full thickness vascular wound- 5.0 x 5.0 x UD (Undermining)- moderate amount of drainage (purulent)- vascular referral pending [DATE]- New onset- Right lateral ankle- Stage: - Full thickness vascular wound- 3.5 x 3.0 x 0.5 - moderate amount of drainage (serous) - vascular referral pending. " A review of the Doctors Progress notes revealed: " [DATE]- Extremity: stiff (left) elbow and bilateral knees; Skin: (right) heel Stage 3 ulcer, (left) leg small ulcer. [DATE]- Nurse Practitioner note- Extremity- No [MEDICAL CONDITION] [DATE]- No leg [MEDICAL CONDITION]; Prognosis: Poor [DATE]- Nurse Practitioner note- Extremity -No [MEDICAL CONDITION] [DATE]- Nurse Practitioner note- Extremity- No [MEDICAL CONDITION] [DATE]- (He/she) is much more alert this month. No [MEDICAL CONDITION]; Continue all present care; Outlook improved [DATE]- Nurse Practitioner note- Extremity- No [MEDICAL CONDITION] [DATE]- Nurse Practitioner note - Extremity- No [MEDICAL CONDITION]. " A review of the "Care Conference Summary" dated [DATE] revealed: " Review of medications and residents general condition. Resident ' s prognosis is poor per MD ' s progress notes. Resident has a (history) of alcohol usage. (History of [MEDICAL CONDITION]). The (resident ' s relative) is aware of a history of poor circulation in the legs. (Named relative) is requesting a meeting with the (Medical Doctor) to further discuss advance directives. Resident continues [MEDICAL CONDITION] [DEVICE]. Remains verbally unresponsive. " [DATE]- " I (Employee #14) was asked to review the chart in reference to vascular surgery referral that had been missed. The reason the visits were cancelled was the contact and droplet isolation status, which precluded a clinic setting. On further evaluation, however, there is no reason for a vascular surgery consultation, since there is nothing that the surgeon would have to offer other than above-the-knee amputation ... I (Employee #14) agree that Comfort Care is appropriate. I (Employee #14) have discontinued further vascular (surgical) consults. " There was no evidence that the physician or the nurse practitioner included the resident ' s vascular wounds, Doppler study results and pending vascular consults in his/her total plan of care prior to [DATE]. A face-to-face interview was conducted with Employees #4 and #34 on [DATE] at approximately 12:30 PM. When queried if an appointment had been arranged for a vascular consult; Employee #34 stated an appointment was made for [DATE]; however the week prior to the scheduled appointment he/she called to follow-up with the doctor ' s office and informed them that the resident was on isolation. The physician ' s office " told me that the appointment will be rescheduled for [DATE] and maybe he/she would be off isolation. " Both acknowledged the aforementioned findings. There was no evidence in the clinical record that Resident #105 had an appointment scheduled for [DATE]; nor that the attending physician or nurse practitioner was informed of the vascular clinic decision to delay the resident ' s appointment secondary to him/her being on isolation. The clinical record lacked evidence that the physician ' s request for a vascular consultation was acted on for a period greater than 60 days (two months)-(81 days) following the initial order ([DATE]). Subsequently, the resident ' s vascular system progressively declined. A review of the medical record revealed that the attending physician made visits on [DATE], [DATE] and 8, 2013. There was no evidence that the physician addressed the Doppler studies results and/or pending vascular consult. A face-to-face interview was conducted with Employee #16 on [DATE] at approximately 1:30 PM. He/she stated (resident named) " vascular system is deteriorating. " A follow- up face-to-face interview was conducted with Employee #14 on [DATE] at approximately 3:00 PM. When queried regarding the vascular consult delay and the communication with the attending regarding resident ' s condition, he/she stated, " Resident is not a good candidate for bypass. Resident needed a second opinion. (He/she) also stated (he/she) did not review the resident ' s condition and discuss the delay of the vascular consult with the attending. (MD named) always is good about reviewing everything. However, (he/she) stated (he/she) will contact the primary doctor today because a different plan of care has to be done today. " He/she acknowledged the aforementioned findings. In conclusion, there was no evidence that the facility acted with timeliness on an order for [REDACTED]. In addition, there was no evidence the facility staff made provisions/arrangements for an in-house (bedside) consultant. Subsequently, the resident ' s vascular system progressively declined. Three (3) new wounds were assessed on [DATE]. The observations and clinical record review was made on [DATE]. 1(b) Facility staff failed to ensure Resident #105 ' s head of bed was elevated in accordance to physician's order [REDACTED]. On [DATE] at approximately 10:45 AM, [DATE] at approximately 3:00 PM and [DATE] at approximately 3:30 PM; Resident #105 was observed lying in bed with his/her head of bed raised at approximately 35 degrees while an enteral feeding was infusing. A signage posted on wall at the head of resident ' s bed instructed: " Elevate head of bed > (greater than) 35 degrees. " According to a physician's order [REDACTED]. " Facility staff failed to elevate the resident ' s head of bed in accordance to physician's order [REDACTED]. A face-to-face interview was conducted with Employees #4 and #6 on [DATE] at approximately 3:40 PM. After assessing resident ' s head of bed elevation; he/she acknowledge the aforementioned findings. The clinical record was reviewed on [DATE]. The observations occurred on [DATE], [DATE] and [DATE]. 2. Facility staff failed to clarify a physician ' s directive to discontinue a medication, [MEDICATION NAME], that was not included in Resident #81 ' s prescribed medication regimen. Further review of the clinical record revealed that a medication of similar name was intended for discontinuence, [MEDICATION NAME]. A review of the closed record for Resident #81 revealed the resident was admitted to the facility [DATE] and expired on [DATE]. A nurse ' s note dated [DATE] at 8:40 AM revealed the resident was found unresponsive as follows: " change in condition nurses notes ...resident was found unresponsive in (his/her) room pulseless and not breathing. Code 6 called. CPR(cardiopulmonary resuscitation) initiated, EMS (Emergency Medical System) called, blood sugar was 60 mg/dl (milligram/decileter). House Doctor responded to code. EMS arrived at 9AM. The code continued by EMS personnel. Resident was transferred by EMS personnel to (hospital named) at 9:25 AM. Went back to room to clean up after the code and found 3 suspicious pipes, 1 brillo pad, a cigarette lighter, 3 empty beer cans. House officer (doctor) was on the unit. (He/she) was made aware of findings ...follow up call made to (hospital named), Resident expired at 9:42 AM as per ER (emergency room ) nurse ... " The physician ' s discharge summary signed [DATE] read: " Disposition ([DATE]): transported to (hospital named) - expired; Admission Diagnosis - probable illicit drug use and intoxication - on the date of death ; uncontrolled Diabetes Mellitus; Hypertension and chronic [MEDICAL CONDITION] ... " A physician ' s interim order dated [DATE] at 3:00 PM read: D/C (discontinue) [MEDICATION NAME] (Adrenergic blocker; antiarrhythmic); D/C (discontinue) previous [MEDICATION NAME] ER (Calcium channel blocker; antiarrhythmic/antihypertensive); [MEDICATION NAME] ER 400mg 1 tablet by mouth daily for hypertension (hold if systolic blood pressure is less than 120 mm/Hg or diastolic blood pressure is less than 70 mm/Hg). A review of the Resident #81 ' s medication regimen, according to the Medication Administration Record [REDACTED]. A review of the Nurse Practitioner ' s progress note dated [DATE] at 4:00 PM read: " Asked to evaluate resident ' s [MEDICATION NAME] " treatment and [MEDICATION NAME] ER treatment due to duplicate therapy. Resident on [MEDICATION NAME] 10mg QD (every day), [MEDICATION NAME] ER 360mg QD, [MEDICATION NAME] 40mg QD, [MEDICATION NAME] 20mg QD; resident ' s blood pressure range ,[DATE] - ,[DATE]. Resident is in (his/her) room, remains stable ... " ok " ; no shortness of breath, no chest pain no nausea vomiting or diarrhea, no acute distress ...assessment: hypertension; plan: discontinue [MEDICATION NAME], increase [MEDICATION NAME] ER to 420mg QD continue blood pressure checks. A review of the Pharmacist ' s Consultation Report dated [DATE] revealed the following: Comment: [AGE] year old male takes duplicate therapy of calcium channel blockers, [MEDICATION NAME] 10mg and [MEDICATION NAME] ER 360 mg daily. Recommendation: Please re-evaluate the need for both agents, perhaps giving consideration to discontinuing use of [MEDICATION NAME]. If dual therapy is to continue, it is recommended that the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual and that the facility interdisciplinary team ensures ongoing monitoring for effectiveness and potential adverse consequences. Following the review of the clinical record, it was determined that the order written on [DATE] was erroneous. There was no evidence that the resident was prescribed Amiodaron and therefore this medication could not be discontinued. However, the NP progress note dated [DATE] revealed the plan for Resident #81 was to discontinue the medication [MEDICATION NAME] ([MEDICATION NAME]). There was no evidence that facility staff consulted with the NP to clarify the order that directed the discontinuence of Amiodaron that was not included in the resident ' s medication regimen. According to the MARs for April and [DATE], the " duplicate " therapy of the [MEDICATION NAME] ([MEDICATION NAME]) and the increased dosage of [MEDICATION NAME] ER (increased by 60mg; formerly 360mg daily and modified to 420mg daily as of [DATE]) was administered for the month of April through [DATE]. A face-to-face interview was conducted with the Director of Nursing (DON) on [DATE] at 4:00 PM. He/she acknowledged the inconsistencies identified with the medications [MEDICATION NAME] and [MEDICATION NAME] for Resident #81 and that [MEDICATION NAME] was never included in the resident ' s drug regimen. He/she denied knowledge of the medication concerns prior to the interview. The DON notified the NP regarding the findings and he/she stated that the NP acknowledged the findings. The record was reviewed [DATE]. 3. Facility staff failed to consistently assess and monitor an alteration in the skin integrity of Resident #126 ' s right earlobe. Resident #126 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident was assessed with [REDACTED]. The [DATE] POS (Physician order [REDACTED]. A " Change in Condition Nurse ' s Note " dated [DATE] at 1:40 PM read: " ...Upon ADL (activities of daily living) care noted an excoriation on right earlobe measuring 1.2 cm x 1cm, NP (nurse practitioner) aware, order written for Xeroform Tx (treatment), RP (responsible party) made aware ... " An assessment of the " excoriated " earlobe was recorded on the facility ' s " Wound and Skin Care Progress Note " dated [DATE] as follows: " facility acquired a Stage 2 right earlobe wound; characteristics: LxWxD (cm) (length bywidth by depth) (centimeter) 1.0x1.0x<(less than)0.1cm; 100% [MEDICATION NAME], yes for drainage scant amount, color consistency serous, no odor, treatment: continue Xeroform dressing qd (everyday) and prn (as needed). " Further review of the clinical record lacked evidence of subsequent documentation regarding the status of the wound of the resident ' s right earlobe. A face-to-face interview was conducted with Employees #4, #5, and #6 on [DATE] at approximately 10 AM. Each acknowledged that there was no further documentation related to the assessment and/or status of the resident ' s right earlobe skin impairment, however stated that the site was healed. The record was reviewed [DATE]. 4. Facility staff failed to obtain a respiratory screen as per the physician orders [REDACTED].#143. The physician's order [REDACTED]. " According to an " Attending Note " dated [DATE]: " [AGE] year old (male/female) admitted post pneumonia, [MEDICAL CONDITIONS]([MEDICAL CONDITION]), (Gastrostomy Tube). Now weaned from trach. " The nurse's noted dated [DATE] at 2:40 PM revealed, "Resident was noted wheezing oxygen at 2 liters via NC (nasal cannula) administered. Vital signs (blood pressure) ,[DATE], (pulse) 84, (respirations) 20 and (temperature) 97.9 ..." [DATE] at 7:00 PM, " Resident noted with respiratory distress and unable to respond. MD (medical doctor) call and (ordered him/her to) transfer the resident to the nearest ER (emergency room ) for evaluation. " A review of the clinical record lacked evidence that facility staff obtained a respiratory screen per the physician's order [REDACTED]. A face-to-face interview was conducted on [DATE] at approximately 11:30 AM with Employees #2 and #6. When queried about the process for obtaining a respiratory screen, Employee #6 stated, " When an order is written for a respiratory screen; respiratory is informed and the screen is conducted by the respiratory therapist. " Both acknowledged a respiratory screen was not present in the clinical record. A follow-up face-to-face interview was conducted with Employee #15 on [DATE] at approximately 1:30 PM. When queried regarding the respiratory screening order, " The respiratory care process is order driven and an initial assessment is conducted before services are rendered. " After reviewing the clinical record; he/she acknowledged a respiratory screen was not conducted for the resident. Facility staff failed to ensure that Resident #143 received a respiratory screen in accordance with the physician orders. The clinical record was reviewed on [DATE]. 5. Facility staff failed to assess the level of Resident #145's pain (numeric rating) pre and post medication administration and failed to fully assess the characteristics of the venous access device utilized for the resident. a.) The physician's order [REDACTED]. " The [DATE] Medication Administration Record [REDACTED] Acet-[MEDICATION NAME] 500mg/5mg 1 tablet was administered on [DATE] at 5:00 AM. Acet-[MEDICATION NAME] 500mg/5mg 2 tablets was administered at 1:30 PM and 9:00 PM on [DATE] and on [DATE] at 10:00 AM. The section of the MAR indicated [REDACTED] [DATE] at 1:30 PM and 9:00 PM, [MEDICATION NAME] 2 tabs, the reason for administration was documented as leg pain and the results were effective. [DATE] at 5:30 AM, [MEDICATION NAME] 1 tab, the reason for administration was documented as leg pain and the results were effective. [DATE] at 10:00 AM, [MEDICATION NAME] 2 tabs, the reason for administration was documented as leg pain and the results were effective. The prn pain medication administration records lacked evidence that the facility staff assessed Resident #145 ' s numeric level of pain to ensure that pain medication administered was consistent with physician's order [REDACTED]. A face-to-face interview was conducted on [DATE] at approximately 9:40 AM with Employee #7. He/she acknowledged that the there were no numeric pain assessments prior to the administration of medication. The record was reviewed on [DATE]. b.) Facility staff failed to fully assess the venous access device utilized for Resident #145. The "Central Venous Catheter-Physician Order/Protocol Sheet " dated and signed by the physician on [DATE] directed, "Device Type: PICC (peripherally inserted central catheter): brand, gauge, and total length " was left blank. There was no evidence that facility staff fully assessed the characteristics of Resident #145 ' s PICC line as it relates to brand, gauge and total length. A face-to-face interview was conducted with Employee #7 on [DATE] at approximately 2:50 PM. He/she acknowledged that the PICC line characteristics were not included on the " Central Venous -Physician Order/Protocol Sheet." The record was reviewed on [DATE].

Based on observations, staff and resident interviews and record review, it was determined that Resident #1 was locked out of the building in the hallway near the outside rear deck from 7:54 PM until 10:11 PM on February 11, 2013 and ensure that the environment residents had access to was free from accident hazards. The findings include: Resident #1 was born on August 9, 1950 and was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) dated [DATE], Resident #1achieved a score of 6/15 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 " 0-7 " suggests that the resident ' s cognitive status was " severely impaired. " Resident #1 was assessed as being independent for locomotion on and off the unit, requiring supervision for eating, extensive assistance for bed mobility, dressing and personal hygiene and totally dependent for transfers, toilet use and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Eye Replacement (left). According to a nurse ' s note dated February 12, 2013 at 11:00 PM and signed by the nurse February 11, 2013: " Vital Signs (V/S) 131/81 (blood pressure), 84 (pulse), 98.2 (temperature), 18 (respirations). Resident was escorted by security staff at 10:15 PM. He/she stated that resident was locked out the hallway, one door to outside the building. Resident denies pain or discomfort, no sign of acute distress noted. No altered mental status noted. Resident was put back to bed. Resident ' s R/P (responsible party) notified. Assessment done. No abnormal findings noted. Nursing supervisor was on unit and also notified. " According to the Security Department ' s incident report dated February 11, 2013 at 22:00 (10:00 PM): " At 2200 patient (Resident #1) was found locked out of the ambulance entrance stuck between the wooden door and the sliding door. (Resident #1) was discovered by (Employee #1) and (Employee #2). The doors to the ambulance ramp were secured at 1955. After viewing the CCTV it was discovered that (Resident #1) went out the door at 1902. No calls were made to the front desk to alert security of a missing patient. Notified (Employee #3). " According to a memo written by Employee #3 and dated February 12, 2013, " Whom It May Concern: This serves as an addendum to a previous report filed concerning (Resident #1). On February 12, 2013 (Employee #3) conducted an additional investigation into the matter concerning a resident being locked out of the facility for a total of 2 hours and 21 minutes. I reviewed the available video footage which shows the following time line. ? 19:02 hours (Resident #1) is observed exiting the facility ? 19:54 hours and 00 sec (Employee #4) secures the rear door ? 19:54 and 30 sec (Employee #4) returns past the camera ? 22:11 hours (Employee #1) and maintenance staff exit building to find resident. On day in question, (Employee #4) was manning the security station alone due to manpower shortage. Upon arrival of (second security officer), Employee #4 began a round to secure the facility. This concludes my report. " Employee #4 typed the following statement dated February 12, 2013 at 1:28 AM: " At 10:48 PM on Monday, February 11, 2013, I (Employee #4) was informed by (Employee #3) concerning (Resident #1) who only had access to the atrium ambulatory area of the facility based on me locking the inner rear facility door at 8:00 PM. Upon me locking the inner rear door, I did not notice any Patients, Visitors, Staff or Ambulatory personnel outside on the loading dock ambulatory entrance. I was not informed of the securing methods for the Ambulatory sliding door. At 11:48 PM I arrived to the Facility and spoke with (Employee #2), who informed me that (Resident #1) was in good condition. All vitals were stable. (Employee #2) also showed me how to properly lock the rear facility sliding door. No further data to report. " Employee #5 wrote and signed the following statement dated February 12, 2013: " Statement for Resident in room (number). At 3:06 PM writer observed resident in the unit by the elevator for 3 - 11 shift. Resident was observed later at about 6:40 PM. I started passing out my medications at 6:55 PM for room (number) and resident was in the hallway when I have him/her medication. I did not see the resident again until 10:15 PM when he/she was brought up by security guard (who) stated that resident was locked out in the hallway one door to outside the building. Resident denies pain and discomfort. Assessment done, no abnormality noted. Resident had his/her jacket on. Nursing supervisor was already aware. R/P notified. Resident put back to bed. 10 PM medication given and was made comfortable. He/she verbalized that she was fine and thanked writer. Incident report was completed per policy. " A physician's order [REDACTED]. Resident #1 received the 9:00 PM dose of Calcium at 6:55 PM, two (2) hours prior to the scheduled time. Employee #6 wrote and signed the following statement dated February 13, 2013: " On 2/11/13, I worked on the 4th floor. I was assigned to rooms (numbers which included Resident #1). Early in the evening I saw (Resident #1) near the elevator in the lobby on the 1st floor. I asked him/her " are you going up to the 4th floor now? " He/she said " No later bye bye. " I had came to get him/her medication. I did not see him/her leave the floor, I was with another patient. Later on while coming out of a patient ' s room, I saw (Resident #1) at the front desk with the supervisor and the nurse. As I went for towels on my cart I saw the nurse was taking his/her vitals. I took (Resident #1) to his/her room to get him/her wash when they were finished. " A face-to-face interview was conducted with Resident #1 on February 13, 2013 at 8:50 AM. Resident #1 was asked about the above occurrence and stated, " I was locked out of the building. I yelled nurse, nurse and kept pulling on the door handles but no one came. I was scared and it was cold even though I had my jacket on. Finally someone came and took me back to my room. I went out to smoke. I have been going out to smoke by myself since I ' ve been here, about five years. I have my own cigarettes and lighter. We can smoke at any time. There is no scheduled time. Sometimes another patient comes down with a nurse to help him smoke. But I don ' t need that. I was okay. " A review of the resident ' s record revealed a " Smoking Assessment " dated June 25, 2012, in which the Interdisciplinary Care Team assessed the resident as an independent smoker. According to the facility ' s policy, " Smoking Policy - Resident, " policy number 6.03, effective dated March 2012, under #8: " Smoking guidelines for residents with independent smoking privileges based on assessment: a. Residents with independent smoking privileges will be permitted to keep cigarettes, pipes, tobacco and safety lighter. b. Residents with independent smoking privileges may not give smoking articles to other residents with restricted smoking privileges. (Note: Anyone who observes this happening will report incident to the Charge Nurse immediately.) " (Restricted residents are required to be escorted.) According to a " Memo Regarding Smoking Schedule for Resident " dated October 29, 2012, from (Employee #7): " This memo reiterates our duty and responsibility to ensure that residents who smoke do so in a safe and secure manner. In view of this, it has become necessary to put a smoking schedule in place to ensure that residents who smoke are monitored for their safety. This will require that all cigarettes and lighters will be held at the nurses ' station until it is time to smoke. This will require those family members that bring cigarettes into the building to drop them off at the nurses ' station. Resident and families will be informed of the new policy regarding the new smoking schedule. The scheduled times to smoke will be as follows: 1. After Breakfast - 10 AM 2. After Lunch - 1:30 PM 3. After Dinner - 6:30 PM This will require a unit schedule for staff members from the 4th and 5th floors. Unit Managers will work with their staff to set up the schedule. Thank you for your cooperation. " A face-to-face interview was conducted with Employee #1 on February 13, 2013 at 10:30 AM. Employee #1 was asked about the above occurrence. He/she stated, " We were replacing the sinks in ICU and I was taking out the trash. I saw (Resident #1) locked in the corridor between the two doors. When I saw him/her I immediately took him/her up to his/her unit. He/she just kept saying thank you, thank you. " Employee #1 was asked about the entry way to the abandoned portion of the building and the corridor opposite the wooden doors. Employee #1 stated, " There was no door on the entry way to the abandoned portion of the building. The door to the corridor opposite the wooden doors was closed but there was no lock on the door. " A face-to-face interview was conducted with Employee #3 on February 13, 2013 at 2:45 PM. Employee #3 was asked about the camera that monitors the access hallway and smoking area. He/she stated, " The camera is a fixed unit and does not rotate. It is aimed at part of the hallway and the ambulance door. It includes some of the smoking area but not the whole area. When it is dark outside, only shadows can be observed through the camera. The picture is not clear enough to identify who is in the area. I noted that the lock on the sliding glass door to the outside was not functioning properly. I reported it to a maintenance person about two weeks ago. That employee is no longer here. I thought that if the wooden doors were locked, that was sufficient. This area is going to be blocked off permanently within the next few weeks for construction. " An observation of the camera ' s picture was conducted at 5:00 PM on February 13, 2013. Upon request of the surveyor and in the presence of Employees #3 and #8, a security guard walked past the camera, down the corridor, out the wooden inner door and out the sliding glass door that residents would use to access the smoking area. The security guard was clearly visible in the camera while walking down the corridor and partially visible while exiting the two (2) doors. When the security guard was outside, only a vague shadow appeared on the camera. It was not possible to identify any characteristics of the security guard from the camera. Additionally, the camera did not cover the entire smoking deck. Additional hazards identified near the smoking area included two (2) corridors that led to the abandoned portion of the building. At the end of the access corridor to the wooden doors leading to the outside sliding door was an entry way to the abandoned portion of the building. There was no door on the entry way. As residents passed through the wooden doors to go outside, there was a corridor of approximately 13 feet long that opened up to another area that contained three (3) trash bins, two (2) trash containers, one (1) desk chair with wheels, one (1) small table with wheels, one (one) rake, one (1) shovel, four (4) mops, one (1) blue linen bin, one (1) housekeeping bucket, two (2) housekeeping carts and one (1) empty 5 gallon container of compressor air fluid. There was a door on the entry way but no lock on the door. The corridor also contained three (3) doors leading to the abandoned portion of the building. Two (2) doors were locked. The door marked " X-Ray Suites " was unlocked and permitted access to the abandoned portion of the building and subsequently the nursing facility. The facility ' s Administrator, Director of Nursing, Assistant Director of Nursing and Director of Security were notified of the facility ' s failure to adequately supervise a resident who was locked out of the building in the hallway near the rear deck for two and one-half (2 ?) hours. The facility failed to initiate any interventions to prevent this event from re-occurring. Additionally, the above cited facility staff was informed that there was no evidence that interventions were initiated to prevent resident from accessing the abandoned portion of the building. An Immediate Jeopardy was identified by the Department of Health at 4:35 PM on February 13, 2013 with a scope and severity of " IJ-J. "

1. Based on observation, staff interview and record review, for one (1) of 19 residents, facility staff failed to provide a bed alarm in accordance with care plan interventions and physician's orders [REDACTED]. Resident #95. The findings include: A review of progress notes in the clinical record for Resident #95 revealed, he/she had a fall on May 1, 2011 - no injury, May 7, 2011- no injury found in a sitting position, and on August 12, 2011 with an injury - cut above left brow. Resident #95 was observed in bed on August 25, 2011 at 11:00 AM without a bed alarm. Facility nursing staff searched the resident's room on August 25, 2011 at 7:30 PM and found the bed alarm in the resident's top dresser drawer. Subsequent to the discovery of the bed alarm, the device was not placed on the resident's bed,and instead it was returned to the top dresser drawer. Another observation on August 26, 2011 at 9:00 AM of Resident #95 noted there was no bed alarm in place. Employee #6 was present during the discovery of the bed alarm in the resident's top dresser drawer and the return of the device to its same location on August 25, 2011. The record was reviewed August 25, 2011. 2. Based on observations during the medication pass conducted on August 25, 2011, facility staff failed to follow physician's orders [REDACTED].#77. The findings include: 1. A review of Resident #56 record revealed a nurse practitioner's order dated August 11, 2011 at 2:30 PM that directed, "[MEDICATION NAME] 3 units sq TID before meals from 8/14/11 when resident returns from LOA (Leave of Absence). Hold if FSBS < 70." During the medication pass observation on August 25, 2011 at 9:10 AM, Employee #12 entered Resident #56's room. The resident stated, "Breakfast was really good. I just finished." Employee #12 asked the resident what he/she had eaten for breakfast. Resident #56 listed the items he/she had consumed for breakfast. Employee #12 then administered [MEDICATION NAME]3 units subcutaneously in the resident's right lower abdomen. A face-to-face interview was conducted on August 25, 2011 at 10:00 AM with Employee # 12. He/she acknowledged that the insulin should have been given before Resident #56 ate breakfast. The record was reviewed August 25, 2011. 2. Facility staff failed to follow physician's orders [REDACTED]. A review of Resident #77's physician's orders [REDACTED].@ lunch" on 7/13/11 and subsequently discontinued the same supplement was written on 7/29/2011. During a family interview of Resident # 77, around 10:00 AM on 8/23/2011, an open can of Ensure Plus was observed on the tray cart in the resident's room. The resident's son confirmed that he had spoon fed his mother the Ensure on that day. A review of the Resident's #77 daily meal ticket obtained from dietary services on 8/25/11 at approximately 5:30 PM listed one (1) of Ensure Plus as a supplement for the resident.

1. Based on observation, staff interview and record review, for one (1) of 19 residents, facility staff failed to supervise the resident as evidenced by failing to provide a bed alarm in accordance with care plan interventions and physician's orders [REDACTED]. Resident #95. The findings include: A review of progress notes in the clinical record for Resident #95 revealed, he/she had a fall on May 1, 2011 - no injury, May 7, 2011- no injury found in a sitting position, and on August 12, 2011 with an injury - cut above left brow. Resident #95 was observed in bed on August 25, 2011 at 11:00 AM without a bed alarm. Facility nursing staff searched the resident's room on August 25, 2011 at 7:30 PM and found the bed alarm in the resident's top dresser drawer. Subsequent to the discovery of the bed alarm, the device was not placed on the resident's bed,and instead it was returned to the top dresser drawer. Another observation on August 26, 2011 at 9:00 AM of Resident #95 noted there was no bed alarm in place. Employee #6 was present during the discovery of the bed alarm in the resident's top dresser drawer and the return of the device to its same location on August 25, 2011. The record was reviewed August 25, 2011. 2. Based on observations during the medication pass conducted on August 25, 2011, facility staff failed to follow physician's orders [REDACTED].#77. The findings include: 1. A review of Resident #56 record revealed a nurse practitioner's order dated August 11, 2011 at 2:30 PM that directed, "Novolog 3 units sq TID before meals from 8/14/11 when resident returns from LOA (Leave of Absence). Hold if FSBS < 70." During the medication pass observation on August 25, 2011 at 9:10 AM, Employee #12 entered Resident #56's room. The resident stated, "Breakfast was really good. I just finished." Employee #12 asked the resident what he/she had eaten for breakfast. Resident #56 listed the items he/she had consumed for breakfast. Employee #12 then administered Novolog insulin 3 units subcutaneously in the resident's right lower abdomen. A face-to-face interview was conducted on August 25, 2011 at 10:00 AM with Employee # 12. He/she acknowledged that the insulin should have been given before Resident #56 ate breakfast. The record was reviewed August 25, 2011. 2. Based on observations made during an environmental tour on the last day of the survey, it was determined that the facility failed to ensure that the facility was free of accident hazards as evidenced by one (1) of three (3) unlocked utility rooms where chemical soaps are stored. The findings include: The access door to the utility room for environmental cleaning solutions the 6 th floor was unlocked and accessible to residents.

Based on observation, staff interviews and record review for one (1) resident, it was determined that the facility staff were not adequately supervised to ensure that two (2) CNAs (Certified Nurse Aide) were assisting Resident #1 during turning and providing care. Subsequently, Resident #1 fell out of bed and sustained a laceration to the forehead. The findings include: Resident #1was born on November 23, 1954 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment completed May 7, 2011, Resident #1was assessed as being in a permanent vegetative state in Section B (Cognitive Patterns). He/she 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 June 5, 2011 at 8:30 AM: " At approximately 6:35 AM, CNA assigned to resident called the writer that " patient fell on the floor while giving him/her care and the resident banged his/her head on the bed side table. " Writer arrived to the room 6130 and met resident lying on his/her back by the bedside. Nursing assessment shows that resident had laceration to the left side of the face/head with swelling and bleeding. Mental status with resident baseline. Neuro checks and range of motion within baseline. Laceration site was cleaned with normal saline, ice pack and sterile 4 x 4 gauze pressure dressing applied to stop the bleeding and swelling. Resident was assisted to bed and made comfortable. No evidence of pain noted on assessment. Nurse Practitioner was notified. Order given to transfer resident to the hospital ER for further evaluation. Supervisor aware and participated in the patient ' s transfer to the hospital ...Patient was medicated for B/P (blood pressure) of 169/96. B/P rechecked before patient transferred to hospital was 144/88 ... Laceration measurement was 2.3 cm x 0.2 cm x 0.1 cm. " A telephone interview was conducted with Employee #1 on July 13, 2011 at 8:03 AM. Employee #1 was giving Resident #1 care when the resident fell out of bed. Employee #1 stated, " (Resident #1) was my last patient and it was 6:30 (AM) and everyone else was busy. I have done Resident #1 by myself before very successfully with no problems. I don ' t know what happened this time - the side rail went down. It was the side rail. " Employee #1 was asked if he/she had attended an in-service recently regarding the facility ' s policy on giving care to dependent residents. Employee #1 stated, " Yes, they told us to use two people for turning and changing a totally dependent patient, but everyone was busy and I needed to finish my patients. It was 6:30 (AM) and the shift changes at 7:30 (AM). I had done Resident #1 myself before without any problem. " Employee #1 acknowledged that he/she had an hour to complete Resident #1 ' s care and should have waited for assistance. Employee #1 was removed from the schedule on June 5, 2011 and terminated on June 7, 2011without returning to the facility to work. An in-service was conducted on April 23, 2011 at 3:30 PM, in which Employee #1 signed as having attended. The " Safe Lifting and Movement of Resident " policy was reviewed at the in-service. The facility ' s policy, #8.27, dated 4/2011, consisting of two (2) pages was reviewed. According to the policy, page 1 of 2, under " II. Policy 4. A two person assist shall be used for all totally dependent residents for transfer, turning and repositioning, providing care and moving of the resident. " This investigation substantiated that the facility staff were not adequately supervised to ensure that two (2) CNAs (Certified Nurse Aide) were assisting Resident #1 during turning and providing care. Subsequently, Resident #1 fell out of bed and sustained a laceration to the forehead. The record was reviewed June 14, 2011.

Based on observation, staff interview and record review for one (1) resident, it was determined that Employee #1, a Certified Nurse Aide (CNA) failed to apply interventions necessary to meet the resident ' s needs. Resident #1 was born on November 5, 1928 and was admitted to the facility on [DATE]. According to the quarterly Minimum Data Set assessment completed on January 27, 2011, Resident #1 was assessed as being in a persistent vegetative state with no response to verbal or tactile stimuli in Section C (Cognitive Patterns). He/she was assessed as being totally dependent for all Activities of Daily Living (ADL) in Section G (Functional Status). His/her weight was recorded as 221 pounds in Section K (Swallowing/ Nutritional Status). Disease [DIAGNOSES REDACTED]. Resident #1 was observed lying on his/her back in bed in the presence of Employee #1. Resident #1 had a [MEDICAL CONDITION] and a gastrostomy tube. He/she did not open his/her eyes when his/her name was called or respond to any questions. The mattress was approximately seven (7) inches below the top of the side rail. Both upper side rails were in the up position. Employee #1 called Resident #1 ' s name and rubbed his/her arm. There was no response from Resident #1. A quarter size red area was observed on Resident #1 ' s forehead above the right eye. Employee #1 touched the area lightly; there was no response from the resident. According to a nurse ' s note dated April 20, 2011 at 3:00 PM: " At approximately 2:20 PM writer heard the CNA(Employee #2) shouting for help. The nurse and other CNAs ...went to(resident ' s room). On arrival resident was observed on the floor on his/her right side. On assessment resident was alert non verbal, pupils equal and reactive to light and accommodation. Resident was noted with swelling above the right eye brow. Assisted back to bed with the assistance of 6 staff members. V/S (vital signs) BP (blood pressure) 133/68, P (pulse) 77, R (respiratory rate) 18, Temp (oral temperature in degrees Fahrenheit 95.9. O2 (oxygen) sat (saturation) 98%.[MEDICAL CONDITION] with no respiratory distress. Ice pack applied to right above the eye brow swelling. Primary physician called for further instructions and instructed to continue with the ice pack application. Responsible Party (RP) also called. Made aware of his/her (family member ' s) fall and injury to right forehead. Writer explained plan of care which included neuro (neurological) checks and ice pack application. Also informed RP to look out for any unusual response by resident, e.g. Resident is able to open his/her eyes when his/her name is being called. Family to notify nursing staff when there is a changed in (his/her) response. We will continue to monitor resident for any changes and update physician as needed. " According to a nurse ' s note " Addendum " to the note cited above with a time of 3:10 PM: " Tylenol 20.3 ml given for pain management s/p (status [REDACTED]. Continue to monitor for pain and medicate as needed. " A face-to-face interview was conducted with Employee #2 on April 21, 2011 at 8:50 AM. Employee #2 was asked about the above cited incident. Employee #2 stated, " I was turning him/her to the side to get the diaper out. It was last rounds, about 2:30 (PM) or so. The diaper was stuck under him/her. I put one arm over the side rail and turned him/her and pushed him/her over a little more to get the diaper out from under him/her. Then he/she went over the side rail and onto the floor. I had a hold of his/her feet so his/her head was maybe only a few inches from the floor when he/she hit it. I screamed for help as soon as it happened and everyone came right away. I have taken care of Resident #1 many times. I know I should not have turned him/her without someone to help me. He/she is a big lady and I am very small. But I have taken care of him/her before with no help, so I thought I could handle it. Everyone was busy at the time, so I thought I could do it by myself. " Employee #2 was hired on March 5, 2001. A revised " Certified Job Description, Performance and Competencies " was signed by Employee #2 on January 9, 2004. Included on page four (4) of six (6) under " Quality- Accountable for safe practice through correct implementation of nursing policies and procedures. " Employee #2 ' s performance evaluations and competency reviews included: April 2, 2009, March 10, 2010 and March 14, 2011. The facility ' s policies were reviewed. The policy for " Safe Lifting and Movement of Residents " , policy number 8.27, revised April 2011, pages 1 and 2, was reviewed. Under " I. Purpose - To ensure safety of residents who meet the criteria for a Two person Transfer to and from a variety of surfaces, including bed, wheelchair, toilet, commode and tub chair. " Under " II. Policy - ...2. Manual lifting of residents shall be eliminated when feasible. 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents ' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include; a. Resident ' s mobility (degree of dependency) b. Resident ' s size c. Weight -bearing ability d. Cognitive status ... " The " Resident Plan of Care " was reviewed and was noted to have been revised on January 27, 2011 and April 20, 2011. Under " Alteration in ADL Function - Approaches - 2 staff to turn and position resident every 2 hours and prn (as needed). " A face-to-face interview was conducted with Employee #1 on April 21, 2011 at 9:45 AM. Employee #1 was asked about the above cited incident. Employee #1 stated, " Employee #2 did not ask for a second CNA to help him/her. All of our persistent vegetative residents are a two person turn. Resident #1 is a big (man/woman) and Employee #2 is a very petite person. I can ' t imagine why he/she thought that he/she could turn Resident #1 by him/herself. " The record was reviewed April 21, 2011.

Based on observations, record review and staff interview for 12 of 23 sampled residents and three (3) supplemental residents, it was determined that facility staff failed to: failed to reassess pain during removal of a dressing from the scalp for one (1) resident, follow-up with the physician's orders [REDACTED]. [REDACTED]. [REDACTED]. Residents # 1, 3, 4, 5, 6, 8, 9, 10, 11, 13, 17, and 21. The findings include: The facility staff failed to stop a wound care treatment and reassess Resident #11 for pain when he/she grimaced and flailed his/her arms during the removal of an old dressing. During an observation of a wound care treatment for [REDACTED].#18 was going to perform a dressing change to the resident occipital area. The second nurse (Employee #14) held Resident #11 on his /her left side and held the resident's head stable so that Employee #18 could remove the old dressing. As Employee #18 began pulling/removing the old dressing from the occipital area, Resident #11 ' s hair was being pulled from his/her scalp. Resident #11 flailed his/her arms and grimaced throughout the entire process of removing the old dressing. Employee #14 stated to Resident #11, "I ' m sorry. Do you want to hold my hand? We are almost done. Okay. It ' s almost over. Sorry for that." Employee #18 continued to remove the old dressing and never stopped to reassess Resident #11 for pain. Once the old dressing was removed Resident #11 stopped grimacing and flailing his/her arms. A review of the August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' s order dated July 29, 2010. The " Wound and Skin Care Progress " note dated August 12, 2010 revealed, " Wound #2 ...Location: Occipital Scalp ...Characteristics: Stage II; 3x4x0.0 cm ...No drainage ...Treatment: Add protective form (foam) dressing qd (every day) and PRN " The interim order dated August 12, 2010 " Occipital Scalp: Cleanse with NS (normal saline), Pat dry, Apply cover with Allvyen foam daily and PRN. " A review of the August 2010 Treatment Administration Record revealed that Resident #11 received a treatment/dressing change to his/her occipital area once daily from August 13 -18, 2010. Although Resident #11 was medicated for pain 30 minutes prior to the dressing change, the facility staff failed to stop and reassess the resident for pain while removing the old dressing. The resident was grimacing and flailing his/her arms while the dressing was being removed. A face-to-face interview was conducted with Employee #18 on August 20, 2010 at 12:21 PM. He/she acknowledged that Resident #11 was in pain and there was no reassessment. The record was reviewed August 20, 2010. 2. Facility staff failed to follow-up with the physician's orders [REDACTED]. A review of Resident #1's clinical record revealed a telephone order on an "Interim Order Form" dated June 18, 2010 at 12:30PM and signed dated by the physician on June 22, 2010 that directed "Neurology consult for evaluation ...and [MEDICAL CONDITION] disorder". The resident's clinical record lacked documented evidence that facility staff followed up with the physician's orders [REDACTED]. A face-to-face interview was conducted with Employee # 13 on August 20, 2010 at approximately 11:25 AM. After a review of the resident's clinical record he/she acknowledged the above findings. The record was reviewed August 20, 2010. 3. Facility staff failed to administer [MEDICATION NAME] every other day as ordered by the physician for Resident #3. The physician's order [REDACTED]. Review of the January 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" [MEDICATION NAME] to 2.5 mg via [DEVICE] every day for 4 weeks. " According the MAR [MEDICATION NAME] 2.5 mg was administered daily from January 21 -30, 2010. There was no evidence that facility staff administer [MEDICATION NAME] 2.5 mg daily in accordance with the physician's order [REDACTED]. A face-to-face interview was conducted on August 18, 2010 at 3:40 PM with Employee #11. He/she acknowledged that the [MEDICATION NAME] 2.5 mg was not administered in accordance with the physician's order [REDACTED]. 4. Facility staff failed to administer [MEDICATION NAME] PRN (as needed) for itching of right buttock wound as orderd by the physician. Resident #4. A review of the physician's orders [REDACTED]. The [MEDICATION NAME] was originally ordered on May 20, 2010 and the order was last signed by the physician on June 13, 2010. Review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]' notes that the resident wore hand mittens to prevent him/her from scratching and reopening wounds on the buttocks. Documentation in the nurses' notes at 3:00 PM on August 3, 2010 stated, "Right hand mitten is maintained to prevent scratching of right buttock wound." On August 4, 2010 at 1:00PM a note stated, "Right hand mitten is in place to prevent scratching of right buttock wound." On August 5, 2010 at 3:00 PM the documentation stated, "right buttock (wound) resurfaced. On August 17, 2010 at 2:00 PM the note stated, "Right hand mitten is in place to prevent scratching of right buttock wound." A face-to-face interview was conducted with Employee #37 at approximately 11:30Am on August 18, 2010. He/she stated, "The resident does not really have new wounds on the buttocks. They are the same wounds. They heal and he/she scratches the areas and they reopen. Sometimes the nurses forget to put the hand mitten on his/her hand and sometimes family members ask us to remove them when they are visiting and they leave without informing us and the mitten is left off." Employee #37 also acknowledged that the resident does have an order for [REDACTED]. The facility staff failed to administer [MEDICATION NAME][MEDICATION NAME] HCL 50mg ([MEDICATION NAME]) one (1) cap (capsule) by mouth every 12 hours as needed to the resident for itching of his/her right buttock wound. The record was reviewed on August 17, 2010. 5. Facility staff failed to clarify the location for the use four (4) pain medications for Resident #5. According the " physician's order [REDACTED].(2) tabs by mouth every 6 hours for chronic pain (not to exceed 4 gms Tylenol from all sources in 24 hours) and [MEDICATION NAME] 20 mg capsules by mouth twice daily for pain. The August 2010 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. While the aforementioned medications are ordered for pain there is no indication of location/site and effectiveness of pain. The record was reviewed August 17, 2010 6. A review of the clinical record for Resident #6 revealed facility staff failed to establish a coordinated plan of care for hospice services. physician's orders [REDACTED]. An initial hospice nursing assessment was performed June 1, 2010 and the resident was admitted as a recipient of hospice services on June 7, 2010. The resident ' s plan of care was amended June 7, 2010 to include the identification of an " immediate-needs care plan - Hospice. " The goals included: " pain and anxiety will be controlled... " Interventions included: " follow hospice plan of care, consult with hospice about resident needs prior to physician contact ... " The record lacked evidence of a delineation of care and services which the skilled nursing facility and the hospice will provide in order to be responsive to the needs of the resident. There was no evidence of a hospice care plan. The record lacked evidence of a coordinated plan of care for both parties. The findings were reviewed and confirmed during a face-to-face interview with Employee #11 on August 19, 2010 at 4:00 PM. 7. The facility staff failed to administer [MEDICATION NAME] in accordance with the physician's order [REDACTED]. The " Interim Order Form " dated July 9, 2010 directed, " ...Start: [MEDICATION NAME] 60 mg P.O. (by mouth) now and every (day) times 13 days. " A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the documentation on the back of the July 2010 MAR indicated ; On July 11, 2010 there was no documentation reason as to why the [MEDICATION NAME] was not administered. A face-to-face interview was conducted on August 19, 2010 at approximately 3:45 PM with Employee #13. He/she acknowledged that the [MEDICATION NAME] was not given on July 10, 2010 as it was not delivered from the pharmacy. The record was reviewed on August 19, 2010. 8. Facility staff failed to administer [MEDICATION NAME] 0.25mg according to physician's orders [REDACTED]. Resident #9. A review of the "Physician order [REDACTED]. A review of the MAR (Medication Administration Record) for August 2010, revealed that a August 15, 2010 9:00 PM dose of [MEDICATION NAME] 0.25 mg lacked initials in the box indicating medication given. Review of the reverse side of the MAR indicated [REDACTED]. A face -to-face interview was conducted with Employee #11 on August 18, 2010 at approximately 2:00 PM. After review of the MAR indicated [REDACTED]. 9. Facility staff failed to follow the physician's orders [REDACTED].#10. A review of Resident # 10 ' s clinical record revealed an unsigned and undated August 2010 ' s " physician's order [REDACTED]. " Rectal tube insertion QD (daily) (9AM -2:00 PM Dx. (Diagnosis) gas distention " and an " Interim order form " dated August 18, 2010 that stated; " Late entry as of 8/13/10: OT (occupational therapist) recommending restorative nsg. (Nursing) to on/off R (Right) knee & (and) (B) (Bilateral) hand splints @ 5x/wk. (5 times per week) X 12 wks for contracture management. " Resident #10 was observed on August 19, 2010 at approximately 1:30 PM. The resident was observed without the ordered right knee and bilateral hand splints. A further review of the resident ' s clinical record revealed that the resident was provided rectal tube insertion and restorative nursing program for on/off bilateral hand and knee orthotic device as evidenced by the initials across from the entries rectal tube insertion and restorative nursing program for on/off bilateral hand and knee orthotic device on the resident's "Treatment Administration Record" (TAR) for August 5 through 19, 2010. A face-to-face interview conducted on August 19, 2010 at approximately 1:45 PM with Employee #25. He/she stated" The ordered rectal tube (between 9:00 AM to 2:00 PM) was not in place during the period of this observation. Employee #25 also acknowledged that the resident was not provided the bilateral hand and leg splints for contracture management as per the physician's orders [REDACTED]. 10. Facility staff failed to follow physician's orders [REDACTED]. A review of the August 2010 physician's orders [REDACTED]." On Wednesday August 18, 2010 at 9:35 AM, the nurse assessed the resident's B/P prior to administering his/her medications. He/she stated that the resident's B/P was 99/77 and the order directed to hold [MEDICATION NAME] if the resident's B/P was low. The observation revealed that the resident did not receive [MEDICATION NAME] for hypertension as ordered. A face-to-face interview was conducted with Employee # 35 on August 18, 2010 at 9:50 AM. He/she acknowledged that based on the parameter set by the physician for holding the medication, [MEDICATION NAME] should have been administered to rhe resident. The record was reviewed on August 18, 2010. Facility staff held [MEDICATION NAME] for B/P reading of 99/77 although the physician's orders [REDACTED]." 11. A review of the clinical record for Resident #17 revealed facility staff failed to obtain a psychiatric consultation per physician's order [REDACTED]. physician's order [REDACTED]. " The record revealed the resident ' s [MEDICAL CONDITION] medication regimen included [MEDICATION NAME] HCL 50 mg 1 tablet at bedtime as needed for [MEDICAL CONDITION]. The record lacked evidence that a psychiatric consultation was performed in accordance with physician's order [REDACTED]. The findings were reviewed and confirmed during a face-to-face interview with Employee #13 on August 20, 2010 at 10:30 AM. The record was reviewed August 20, 2010. 12. Facility staff failed to obtain weights per physician orders [REDACTED]. The findings include: Facility Policy POLICY Title: Body Weight Changes Policy Number: Effective Date: 4/2008 Department: Nursing - SNF Date Reviewed: 3/2009 A. Residents admitted to Capitol Hill Nursing Center will be weighed within 24 hours of admissions and weekly for four weeks there after .... E. Significant weight deviation is defined as unexpected weight loss or weight gain of 5% or more in one month, 7.5% in three months, 10% in six months, and also 2% in one week. PROCEDURE 1. The nursing staff will weigh resident upon admission and readmission within 24 hours and document in medical records. 3. The current weight will be compared to the previous weight to determine the deviation .... 4. Staff will reweigh patient/resident if weight loss or gain is equal to or greater than five pounds for one week, 5% or more for one month, 7.5% or more for three months, and 10% for six months. .. The resident was readmitted to the long term care facility on July 01, 2010 following an admission to an acute care facility. Physician orders, dated and signed on July 01, 2010 direct: ...Weight weekly X 4 ...then Q (every)month The resident was readmitted to the long term care facility on July 23, 2010 following an admission to an acute care facility. Physician orders, dated and signed on July 24, 2010 direct: ...Weight weekly X28 days A review of the Weight Sheet for Resident # 21reveals the following: (Admission) 05/27/10 140.4 lbs nurse signature 06/03/10 145,8 lbs nurse signature (Re-admit) 07/01/10 154 lbs nurse signature ( Re-admit ) 07/23/10 138.4 lbs nurse signature 08.08/10 no documentation follows date The resident was transferred back to acute care on August 17, 2010 The clinical record lacks documentation that the resident ' s weight was monitored weekly times 4 weeks per the physician's order [REDACTED].