Every finding on record at Capitol City Rehab and Healthcare Center

Number of residents sampled: Number of residents cited: Based on record reviews and staff interviews for two (2) of 65 sampled residents, it was determined that the facility's staff failed to ensure residents were provided with adequate monitoring and supervision as evidenced by one resident who sustained a fall with injury when she was left unattended in her room, in a bed that was positioned in the highest raised position and another resident who sustained a fall with injury during an assisted shower. Residents' #95 and #258. The findings included: A facility policy titled 'Fall Prevention Program' with a review date of 08/15/2025 documented, in part: Definitions: A fall refers to unintentional change in position coming to rest on the ground, floor.5. Low/Moderate Risk Protocols: a. Implement universal interventions that decrease the risk of resident falling, including, but not limited to: ii. Bed is locked and lowered to a level that allows the resident's feet to be flat on the floor when the resident is sitting on the edge of the bed.6. High Risk Protocols: b. Implement interventions from Low/Moderate Risk Protocols. d. Provide additional interventions as directed by the resident's assessment, including but not limited to: vi. Low bed. Resident #95 was admitted to the facility on [DATE] with multiple diagnoses that included: Difficulty Walking, Muscle Weakness, Severe Anemia and Fibromyalgia. A nursing progress note dated 02/04/25 at 23:14 [11:14 PM] documented, in part: readmission: Received resident in bed alert and verbally responsive. A nursing progress note dated 02/04/25 at 23:15 [11:15 PM] documented, in part: Writer was called to [room number] that resident had a fall. On entering the room resident was observed on the floor in a supine position between bed-A and Bed-B. Writer was informed by the assigned nurse that resident fell at 11:15pm. When writer inquired from the resident what happened? [The] resident said, I jump[ed] out the bed trying to get to my chair. On assessment resident is A/O (alert and oriented) x 2-3 (resident was not completely oriented) with her speech clear and coherent for her baseline status. Resident was observed with a swelling on her right forehead with a superficial open area . order given to transfer resident to the ER for further evaluation and treatment. A Situation, Background, Assessment, Request dated 02/04/2025 at 23:15 [11:15 PM] documented, in part: Resident had a fall and observed with a swelling on her right forehead with a superficial open area . Mental Status or Neuro Changes: 3a. Confusion. A Quarterly Falls Risk Evaluation dated 02/04/2025 at 23:15 [11:15 PM] documented that the resident was a Moderate Falls Risk, could not walk, was confined to a chair and unable to independently come to a standing position. A nursing progress note dated 02/04/25 at 23:20 [11:20 PM] documented, in part: Received resident around 11:03am [sic] [11:03 PM] and writer went to room and check resident. V/S (vital signs) check[ed], and writer noted the bed was high. Writer attempted to fix the bed, but the bed will not go down . writer went to informed [sic] [inform] the supervisor about fixing the bed. Than [sic] [Then] around 11:15pm resident fell [from the bed] and [I] went to assessed [sic] [assess the] resident. She was lying on her face. She was bleeding and swelling on her right forehead. Writer apply [sic] [applied] pressure and report given to the incoming nurse for follow up. Every body [sic] [everybody] went and attempted to transfer resident [back] in[to] bed. A Facility Reported Incident [Intake Number: DC00013444] received by the State Agency on 02/05/25 at 01:03 [1:03 PM] documented the following, in part: On 2/4/2025 at about 11:15 pm [Resident #95's name] fell out of bed and sustained a superficial open area with swelling to her right forehead . The charge nurse assigned to resident was interviewed she stated that the bed was in a high position, and she was not able to lower the bed, she stepped out to get a CNA (Certified Nursing Assistant) in the room when she returned the resident was on the floor. A hospital consult note dated 02/05/25 at 6:51 AM documented, in part: Small abrasion to right forehead . Neurosurgery was consulted after CT (computerized tomography scan) head showed small subdural hematoma [trauma-induced brain injury] (2mm) (millimeter). A hospital Discharge summary dated [DATE] at 08:15 [8:15 AM] documented, in part: Hospital Course, presents via (by) EMS (Emergency Medical Services) from [Nursing facility name] after a fall. Patient indicates the bed was broken and she was trying to stand to get to her wheelchair when she fell, striking her head on the floor. During a telephone interview conducted on 01/30/26 at 2:20 PM Employee #14 (Licensed Practical Nurse) stated, I didn't witness the fall. When I did go into the room, she was on the floor and the bed looked like it was about waist height, it wasn't in the lowest position. During a telephone interview conducted on 01/30/26 at 2:30 PM Employee #13 (Nurse Supervisor) stated, She was a readmission, I was alerted by one of the nurses who said one of the patients [a resident] was on the floor. I rushed to the room and the bed was elevated. Her mentation was not that great, but I do know her bed was elevated to the max elevation, and it wouldn't go down. The protocol when a resident comes back from the hospital, the nurse should assess the resident to make sure head-to-toe assessment is done to make sure it's the same resident you're getting back from the hospital that you sent out. A fall assessment should've been done and the first thing I asked when I went in[to] the room is Why is the bed so high? because the bed should be low, everything should be in close proximity to the resident, so they don't have to reach. A lot of things were out of place; these are things you do when you get a resident back from the hospital and on admission for safety. During a face-to-face interview conducted on 02/04/26 at 1:25 PM Employee #3 (Director of Nursing) acknowledged the findings and stated, Fall evaluations are done on admission, quarterly and per fall incident. The bed should always be in the lowest position while the resident is still in it; you don't leave a resident alone in a bed that's elevated. 2. Resident #258 was admitted to the facility on [DATE] with multiple diagnoses including Muscle Weakness, Lack of Coordination, and Left side Hemiparesis. A fall risk assessment dated [DATE] documented that the resident had a fall risk score of 9 indicating the resident was a moderate risk for falls. A quarterly MDS dated [DATE] documented that the resident had a Brief Interview for Mental Status score of 8 indicating the resident cognitive status was moderately impaired. The resident was coded as being dependent on staff for showers. The resident was not coded for falls prior to admission or since admission to facility. A nursing progress note dated 01/30/25 at 3:15 PM documented, Around 1:45pm assigned CNA [certified nursing assistant] reported to writer that during shower time she and another staff assisting by trying to turn resident to the side, and resident sustained a fall. Resident stated that he fell in the shower room when he was being given a shower. Writer assessed resident and resident was noted with swelling on his right forehead. The resident was noted with no cut, no bruises, no laceration to any part of his body except for the swelling to his right forehead. On assessment, the resident denied pain and refused pain medication. V/S temp-97.9, P-78, R-18, B/P-139/80 and oxygen saturation of 97% in room air. [DNP's name] notified and an order was given to apply ice pack every 30 minutes on affected area and to transfer resident to the nearest ER [emergency room] for CT scan [diagnostic radiology test] for RT [right] forehead swelling . 911 was called and arrived around 2:17pm and resident refused to go to the ER. Writer and unit manager attempted to talk to the resident and resident refused to go.[Physician's name] was at the facility, and he was able to convince the resident to allow hospital transfer, finally resident agreed and left the unit via at 2:30 pm . The unit manager's note dated 01/30/25 at 4:39 PM documented in part, It was reported by the charge nurse that this resident sustained a fall. A physician order dated 01/30/25 instructed, ER (emergency room) transfer to due CT Scan of the forehead due to swelling. A nursing note dated 01/31/25 at 7:56 AM documented in part, Writer received report at start of shift that resident was transferred to [Name of hospital] emergency department, for evaluation status post fall. A nursing note dated 01/31/25 at 10:51 PM documented in part, Resident returned from [hospital's name] secondary to contusion and swollen to the forehead that occurred on 1/30/25. During a face-to-face interview on 01/22/26 at 4:27 PM, Employee #6 (CNA) stated that Employee #5 (CNA) called him to assist with a shower for Resident #258. Employee #5 turned the resident toward him. His hands were slippery with soap, so he couldn't stop the resident from hitting his head on the wall. The employee said that the resident had some swelling to his forehead after he hit his head. Additionally, Employee #6 stated that he was on the side of shower bed near the wall. During a telephone interview on 01/23/26 at 9:28 AM, Employee #5 (assigned CNA) stated that she turned the resident toward the wall where she was standing in the shower room. The resident then hit his head on the grab bar on the wall when he was trying to pull himself over. When asked, why was the resident so close to the wall where he could hit his head, the employee stated that the resident is a 2 person assist with showers and the room is too small for two people. Additionally, the employee said that she did not tell the nurse that the resident fell. During a face-to-face interview on 01/23/26 at 10:30 AM, Employee #7 (RN/Unit Manager) stated that the nurse and the resident told her that he fell in the shower room while staff was giving him a shower. The employee stated that she could not explain how the resident sustained a hematoma [to the head - localized bleeding outside blood vessels] while 2 staff members were assisting him with a shower.

Number of residents sampled: Number of residents cited: Based on an observation and a staff interview the facility failed to ensure survey results were placed in a readily accessible area where individuals wishing to examine the results do not have to ask to see them for 65 of 65 sampled residents/resident's family.The findings included: An observation of the lobby on 01/23/26 at approximately 3:30PM revealed a binder label Survey Results behind the receptionist desk. During a face-to-face interview on 01/23/26 at 4PM, Employee #9(Receptionist) stated that the Survey Result Binder is always stored behind the receptionist desk. The receptionist will give the binder to anyone if they request to view it.

Based on record reviews, and staff interviews for one (1) of 65 sampled residents, the facility staff failed to develop and implement a comprehensive person-centered care plan with measurable objectives and individualized interventions to address the resident's allergy to eggs and preference for double portions at each meal. Residents #316 and #89. Resident #89 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis, Type 2 Diabetes with Hyperglycemia, Discitis, End Stage Renal Disease, and Weakness. A review of Resident #89's medical record revealed the following: A physician's order dated 02/21/25 that stated: LCS/NAS (low concentrated sweets/no added salt) diet, regular texture, thin liquids consistency. A History and Physical assessment dated [DATE] at 12:00 AM that documented: .C . 2.Meds .Allergies: aspirin, codeine, and eggs. A comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Summary Score of 14, indicating that the resident had intact cognition and the resident had a therapeutic diet (e.g., low salt, diabetic, low cholesterol). A comprehensive care plan revised on 01/13/26 lacked documented evidence that the resident's preference for double portions and his egg allergy were addressed. During a face-to-face interview on 02/09/26 at approximately 10:15 AM, Resident #89 asked, Who do I talk to about my meals from this past weekend? I don't know why they (facility staff) can't get my food right. They keep sending me eggs at meals, and I have an allergy to eggs, and they are not sending me double portions. I am supposed to get double portions. The resident then stated I have taken pictures as evidence, and I have called down to the kitchen and spoken with [Director of Kitchen Services] myself on several occasions. The Resident then provided the following: 1. A photo dated 02/07/26 of Resident #89's breakfast meal ticket that showed: Diet order: Regular, No Added Salt, No Concentrated Sweets, Thin Liquids. Allergies: Eggs. Notes: 2x meat/protein/Double Portions. Dislikes: seafood, eggs, fish. Standing Orders: 1/2 cup grits (x3 butter); 4 x turkey sausage or bacon, 1 slice whole wheat toast (2x grape jam). 2. A photo dated 02/07/26 of Resident #89's breakfast tray that showed a slice of whole wheat toast cut in half and one slice of breakfast ham. 3. A photo dated 02/07/26 of Resident #89's lunch meal ticket that showed: Diet order: Regular, No Added Salt, No Concentrated Sweets, Thin Liquids. Allergies: Eggs. Notes: 2x meat/protein/Double Portions. Dislikes: seafood, eggs, fish. 4. A photo dated 02/07/26 of Resident #89's lunch meal that showed a chef's salad with chopped boiled egg. During a face-to-face interview on 02/10/26, the Director of Nursing/DON stated that the Residents' comprehensive care plans are implemented by the unit managers, nursing supervisors, DON, or other staff (Physical, occupational, or speech therapist, Social Work, Dietician) based on the focus area identified on the care plan. During a face-to-face interview on 02/10/26 at 2:15 PM, Employee #38 (Registered Nurse/ 3 South Unit Manager) stated that she was familiar with Resident #89, although the Resident was not on her unit. She explained that she was covering the unit where Resident #89 resided. When asked if a resident's comprehensive care plan should include the resident's food allergies and preferences, the Employee stated, Yes, and provided no further comment.

Number of residents sampled: Number of residents cited: Based on interview and record review, the facility's staff failed to ensure a resident's packages were not open by staff before delivery for one (1) of 65 sampled residents. (Resident #10) The findings included: Resident #10 was admitted to the facility on [DATE] with multiple diagnoses including Obesity, [NAME] 2 Diabetes, and Congestive Heart Failure. A quarterly Minimum Data Set assessment dated [DATE] indicated that the resident had a Brief Interview for Mental Status summary score of 15 which means the resident had an intact cognitive response, indicating normal thinking and memory. A review of the Resident Rights documented that the resident has the right to have privacy in.getting mail.During the task of Resident Council meeting on 01/14/26 starting at 2:43 PM Resident #10 stated that staff opened 2 amazon packages he had delivered to the facility. The resident said that staff informed him that they opened the packages because they thought the packages belonged to the facility. The resident could not remember who the employee was or the date the packages were delivered. During a face-to-face interview on 01/15/26 at approximately 10AM, Employee #8 (Recreation aide) stated that she delivers mail to resident. The employee also said that she had an incident when a resident's package was opened and she refused to deliver it. She informed the person who had the package that they had to deliver it to the resident because it was open. The employee could not remember the employee or resident related to that incident.

Number of residents sampled: Number of residents cited: Based on observations and interviews, the facility staff failed to provide a safe, clean, and sanitary environment for residents.The findings include:During an environmental walkthrough of the facility conducted on January 21, 2026, between 10:30 AM and 2:00 PM, the following concerns were identified in 22 of 52 resident rooms and kitchen areas:1. room [ROOM NUMBER]: Resident's nightstand surfaces were soiled; baseboard was missing.2. room [ROOM NUMBER]: Moisture-damaged ceiling tiles; broken hand-washing soap dispensers at the toilet room and hand-washing sink; loose toilet handrail; broken toilet seat; counter surface for hand-washing sink was in poor repair.3. room [ROOM NUMBER]: Loose toilet handrail; missing baseboard under the air-conditioning unit.4. room [ROOM NUMBER]-B: Missing pillowcase; stained blanket; stained bedrail.5. room [ROOM NUMBER]: No hand-washing soap provided.6. room [ROOM NUMBER]: Resident wardrobe cabinet door was broken.7. room [ROOM NUMBER]: Loose toilet handrail.8. room [ROOM NUMBER]: Loosely attached hand-washing soap dispenser in restroom; wardrobe cabinet door was in poor repair.9. room [ROOM NUMBER]: Sticky floor in restroom.10. room [ROOM NUMBER]: Electrical outlet missing faceplate; hand-washing sink was clogged.11. room [ROOM NUMBER]: No hand-washing soap provided.12. room [ROOM NUMBER]: Broken hand-washing soap dispenser.13. room [ROOM NUMBER]: Broken hand-washing soap dispenser.14. room [ROOM NUMBER]: Detached baseboard.15. room [ROOM NUMBER]: Missing trash can in restroom.16. rooms [ROOM NUMBERS] (shared restroom): Toilet handrail was loose; hand-washing sink hot water faucet valve was broken; slow drainage observed at the hand-washing sink in the tub room.17. rooms [ROOM NUMBERS]: Clogged hand-washing sink drain.Kitchen observations:18. Damaged drywall at the delivery receiving area.19. Dust build-up on ceiling tiles and metal grids above the rack for clean utensils.20. Three-compartment dish sink area had an unclean backsplash stainless steel wall cover.21. Significant grease buildup on cooking equipment.22. Missing ceiling tile above the dishwashing area.These observations were acknowledged by Employee #20, Food Service Director, on January 6, 2026, at approximately 10:00 AM, and by Employee #19, Maintenance Director, and Employee #23, Environmental Services Director, on January 21, 2026, at approximately 2:00 PM.Facility leadership was made aware of these findings during the survey and stated they would implement measures to address the identified concerns.

Number of residents sampled: Number of residents cited: Based on record review and staff interviews for two (2) of 65 sampled residents, it was determined that the facility's staff failed to provide written notice of a resident's discharge from the facility, including bed hold policy with number of bed hold days, notification to the Long Term Care Ombudsman and State Agency to the resident or their representative upon transfer to the emergency room. Residents' #95 and #301. The findings included: 1.Resident #95 was admitted to the facility on [DATE] with multiple diagnoses that included: Difficulty Walking, Muscle Weakness, Severe Anemia and Fibromyalgia. A Discharge Return Anticipated Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 'Severely Impaired'. A nursing progress note dated 02/04/25 at 23:15 [11:15 PM] documented, in part: Writer was called to [resident's room number] that [the] resident had a fall. On entering the room, [the] resident was observed on the floor in a supine position between bed-A and Bed-B. Resident was observed with a swelling on her right forehead with a superficial open area. [Nurse Practitioner's name] [was] notified and order given to transfer resident to the ER (emergency room) for further evaluation and treatment. resident was transfer[ed] from the facility to [hospital name] at 12:35AM. A care plan dated 02/04/25 documented, in part: Focus: [Resident #95's name] had a fall in her room sustaining a swelling with open area on her right forehead on 02/04/25 . Interventions: Transfer resident to ER for further evaluation/treatment. A review of Resident #95's medical record on 01/28/26 at approximately 3:30 PM, revealed that there was no documented evidence that facility staff provided written notification of the resident's discharge from the facility. 2. Resident #301 was admitted to the facility on [DATE] with multiple diagnoses that included: Stroke w/ hemiplegia affecting left side, Hypertension, Diabetes Mellitus and Deep Vein Thrombosis. An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15,' indicating the resident was cognitively intact. A Social Worker progress note dated 02/20/25 at 14:04 [2:04 PM] documented, in part: Family contacted writer requesting transfer to the hospital.Writer informed family that resident doesn't have medical reason to be transferred, but if the family believes the resident should be transferred it is within their rights to proceed with the request. Writer informed clinical team of request. Facility completed transfer per family's request. Non-emergency transport was arranged to [hospital name]. A physician order dated 02/20/25 at 14:45 [2:45 PM] documented, Per resident's request: Transfer resident to the nearest hospital via non-emergency transportation. A review of Resident #301's medical record on 02/09/26 at approximately 2:20 PM, revealed that there was no documented evidence that facility staff provided written notification of the resident's discharge from the facility. During a face-to-face interview conducted on 02/09/26 at approximately 2:45 PM, Employee #10 (Director of Social Work) acknowledged the findings and stated, I don't know of any reason why the 6-108 (Notice of Discharge, Transfer or Relocation Form) wouldn't be filed in the record if it was done. Cross reference: DCMR S 3270.1

Number of residents sampled: Number of residents cited: Based on record review and staff interviews, the facility failed to complete a Significant Change in Status Assessment (SCSA) in the Minimum Data Set (MDS) within 14 days after the facility determined or should have determined that a significant change had occurred for Resident #313. The resident experienced a non-self-limiting weight loss of 5.8% in 30 days (117.4 lbs on [DATE] to 110.6 lbs on [DATE]) and was not on a physician-prescribed weight-loss regimen. This deficient practice affected 1 of 65 sampled residents.Resident #313 was admitted on [DATE] with diagnoses including neurocognitive disorder with Lewy bodies, Parkinson's disease without dyskinesia and without fluctuations, adjustment disorder with anxiety, adult failure to thrive, dysphagia (oropharyngeal phase), anorexia, and cognitive communication deficit.The resident required extensive to total assistance for Activities of Daily Living (ADLs), was always incontinent of bladder and bowel, exhibited coughing or choking during meals and medication administration, and had one unhealed Stage 4 pressure ulcer on admission. Care Area Assessments were triggered for cognition/dementia, communication, incontinence, falls, nutritional status, pressure ulcer, and return to community referral.The admission MDS dated [DATE] documented the resident was unable to complete the Brief Interview for Mental Status (BIMS) and had severely impaired cognitive skills for daily decision-making.A quarterly MDS dated [DATE] documented, in part, the resident had short-term memory problems, severely impaired decision-making, total dependence for self-care and mobility, frequent bladder and bowel incontinence, unhealed pressure ulcers (two Stage 3 and two Stage 4, one present on admission), and weight loss of 5% or more in one month or 10% in six months (coded Yes) while not on a physician-prescribed weight-loss regimen. The resident was receiving a mechanically altered diet and an antidepressant (high-risk medication).A Medical Orders for Scope of Treatment (MOST) dated [DATE] indicated CPR - Attempt Resuscitation; Medical Interventions - Full Treatment.Significant Weight LossFacility weight records revealed: 117.4 lbs on [DATE] 110.6 lbs on [DATE]This represented a 5.8% weight loss in 30 days, meeting the facility's and RAI criteria for significant, unplanned weight loss requiring comprehensive reassessment and an SCSA.There was no evidence the facility completed an SCSA within 14 days of identifying or when it should have identified the significant weight loss.During a face-to-face interview on [DATE] at approximately 1:35 PM, Employee #27 (RN, 2-South Unit Manager) stated the resident had poor oral intake and multiple pressure ulcers. The RN stated that when significant weight loss is identified, nursing notifies the dietitian and physician and documents in progress notes; however, the RN did not recall that Resident #313 had significant weight loss.During a face-to-face interview on [DATE] at approximately 2:58 PM, Employee #28 (LPN) stated the resident was non-verbal, a feeder, had poor oral intake, required encouragement to eat, had an unhealed sacral wound on admission, was repositioned every two hours, later developed an ear wound, and was eventually transferred to the hospital for poor oral intake.During a face-to-face interview on [DATE] at approximately 3:43 PM, Employee #29 (Wound Nurse) stated the resident had poor nutritional intake, multiple pressure ulcers, bladder and bowel incontinence, and impaired mobility, all of which could negatively impact wound healing.During a face-to-face interview on [DATE] at approximately 11:25 AM, Employee #21 (Dietitian) stated the resident was on a mechanical soft diet, later changed to puree at family request, and received MedPass three times daily and ProSource [both nutrition supplements] twice daily since admission. The dietitian stated she was not consulted regarding the possibility of a feeding tube, which would require a physician order, and indicated the resident's weight loss had been gradual. The dietitian further stated that if speech therapy had recommended puree earlier, the diet could have been changed prior to the family request.During a face-to-face interview on [DATE] at approximately 2:10 PM, Employee #30 (Wound Nurse Practitioner, Healing Partners) stated the resident was frail, thin, underweight, with prominent bony areas, and recommended the dietitian increase protein intake to support wound healing.During a face-to-face interview on [DATE] at approximately 3:10 PM, Employee #21 (Dietitian) stated that unplanned weight loss of 5% or more in 30 days is significant and requires intervention. The dietitian stated she was not aware of the resident's 5.8% weight loss between [DATE] and [DATE] and was not employed at the facility at that time.During a face-to-face interview on [DATE] at approximately 4:00 PM, Employee #3 (Director of Nursing) stated that monitoring weight is the responsibility of all disciplines and that unplanned weight loss should be reported to the responsible nurse, dietitian and physician. When asked whether a 5% weight loss constituted a significant change requiring assessment, the DON deferred to the dietitian as the most appropriate person to address that determination.Despite documented significant, unplanned weight loss, clinical indicators of poor oral intake, dysphagia, multiple non-healing pressure ulcers, total dependence for feeding, and failure to thrive, and staff acknowledgment that such weight loss is significant and requires intervention, the facility failed to initiate and complete an SCSA within 14 days as required.The facility failed to ensure a Significant Change in Status Assessment was completed within the required timeframe for Resident #313 following a 5.8% unplanned weight loss in 30 days, in accordance with S483.20(b)(2)(ii). This failure had the potential to delay identification and implementation of necessary interventions to address the resident's declining nutritional status and wound healing needs.

Based on record review and staff interview for two (2) of 65 sampled residents, facility failed to update one resident's care plan to include ophthalmology visits and update another resident's care plan with new goals and interventions status post unwitnessed fall with injury. (Residents #11 and #309)Findings Include . Resident #11 was admitted to facility on 08/25/2017 with diagnosis anemia, Polyneuropathy, Atherosclerotic Heart Disease, Peripheral Vascular Disease, HIV Presbyopia and Dry eye Syndrome of Bilateral Lacrimal Gland. The resident#11 during interview reported to the surveyor I want to see the ophthalmologist. Review of the resident medical record on 2/6/2026 showed the resident was last seen by the Ophthalmologist on 12/31/2021. Review of the ophthalmologist report dated 12/31/2021 showed recommended follow up visit for the patient in 1year Review of care plan showed resident was seen by the ophthalmologist three times since admission [DATE], 12/29/2021 and 12/31/2021, the Ophthalmologist recommended two times the F/u (follow up) visit. There was no mention on updated care plan documentation that the patient had follow up visit with his ophthalmologist. Further review of the Resident Progress Note showed no documented evidence that the ophthalmologist visit was followed up indicating not Done. Interview with Employee#7 [1North Unit Nurse Manager] on 02/04/2026 at 10:15 am concerning patient wanting to visit the ophthalmologist She made an appointment for the resident to see the in-house doctor on 2/6/2026. A face-to-face interview was conducted on 02/13/2026 at approximately 10am with Employee#3 [Director of nursing] who was made aware of concern that the care plans were not being updated 2. A review of Resident #309's medical record revealed: Resident #309 was admitted to the facility on [DATE] with multiple diagnoses that included: Leukemia, Dementia, Asthma, and Respiratory Failure. An admission Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '02,' indicating the resident was cognitively impaired. Functional abilities that documented: the resident required substantial to maximal assistance from staff for standing and walking; partial to moderate assistance from staff for transfers; and used a wheelchair for locomotion. A nursing progress note dated 05/25/25 at 09:45 [9:45 AM] documented, in part: Around 7:40am writer heard someone call for help and writer went in room. Resident was found leaning on her right side next to closet. Upon assessment resident noted with skin tear on her RT (right) elbow.[Nurse Practitioner's name] [was] notified and order [was] given to do X-ray of the RT (right) side for evaluation due to resident complaint of pain after fall . [Nurse Practitioner's name] call[ed] back and gave order to transfer resident to the nearest ER (emergency room) for further evaluation due to resident complaint of RT (right) side pain after fall. [Nurse Practitioner's name] gave order to clean the RT elbow skin tear with NSS, apply bacitracin and cover with dry dressing daily. A physician's order dated 05/25/25 documented, X-ray of the RT (right) side to evaluate due to resident complain of pain after fall and Transfer resident to the nearest ER (emergency room) due to resident complain of RT (right) side pain after fall for further evaluation. A hospital clinical summary dated 05/25/25 documented, in part: . seen as a trauma consult after being found down with likely fall, with right femoral neck fracture, right ulnar fracture. Underwent CMN (Cephalmedullary Nail) on 5/26[/25] and R (right) olecranon ORIF (Open Reduction and Internal Fixation) on 5/27[/25] A care plan dated 05/25/25 documented, in part: Focus: Skin Tear to right dorsal elbow. Interventions: Encourage good nutrition and hydration in order to promote healthier skin. Monitor/document location, size and treatment of skin tear. Report abnormalities, failure to heal, s/sx (signs and symptoms) of infection, maceration etc. to MD (medical doctor). Treatment as ordered . A care plan dated 06/04/25 documented, in part: Focus: [Resident #309's name] has diagnosis of displaced fracture of greater of trochanter of right femur initial encounter for closed fracture with surgical site and staples . Interventions: Orthopedic consult. It should be noted that Resident #309's care plan was not updated to include the fact that she had an unwitnessed fall in her room on 05/25/25. A facility policy titled 'Documentation in Medical Record' with a review date of 08/14/2025 documented, in part: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation.2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. During a face-to-face interview conducted on 02/11/26 at 10:40 AM Employee #3 (Director Of Nursing) Acknowledged the findings and stated, When residents are admitted the care plan is initiated then updated every month or when needed by the unit manager; like with incidents such as a fall, it should be updated. Cross Reference: DCMR 3210.4 (c)

Number of residents sampled: Number of residents cited: Based on record review and staff interviews, the facility failed to ensure the necessary services of activities of daily living such as personal hygiene, mobility, toileting and hydration were provided for one (1) of sixty-five (65) sampled residents (Resident #302), who was dependent on staff for activities of daily living.Findings include:Resident #302 was admitted to the facility on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, Diffuse Traumatic Brain Injury, Chronic Idiopathic Constipation, Schizoaffective Disorder (Depressive Type), Need for Assistance With Personal Care, Flaccid Hemiplegia Affecting Left Dominant Side, Contracture of Muscle Left, and Aphasia.An admission Comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 07, indicating severe cognitive impairment. The MDS coded the resident as dependent on staff for toileting and personal hygiene, dependent for bed mobility (rolling left and right and sit to lying), using a manual wheelchair, and frequently incontinent of bowel and bladder.A review of the current care plan dated 08/21/2025 documented in part:Focus: Resident has bowel incontinence.Goal: Resident will not have complications related to incontinence through next review date.Interventions: Check resident every two hours and assist with toileting as needed; observe pattern of incontinence and initiate toileting schedule if indicated; provide bedpan/bedside commode; provide loose fitting, easy-to-remove clothing; provide pericare after each incontinent episode.A review of the Certified Nursing Assistant (CNA) task documentation for 06/30/2025 (night shift) revealed no documentation that Resident #302 received the necessary nursing care services. Furthermore, the CNA task documentation report for that date and shift showed the following tasks left blank or undocumented for Resident #302: Additional fluids, bed mobility, bowel incontinence, bowel movements, new skin observation, personal hygiene, toileting hygiene, and turning and repositioning.A review of the facility resident care assignment sheet for 06/30/2025 (Unit 2-South, night shift) revealed one (1) nursing supervisor, two (2) charge nurses, and five (5) CNAs were assigned.During a phone interview on 02/12/2026 at approximately 12:50 PM, Employee #31 (LPN), who worked the night shift (11:00 PM-7:00 AM) on 06/30/2025 as a charge nurse on Unit 2-South, stated Resident #302 was a total care resident dependent on staff for bowel care. She stated she was not aware of any complaints regarding care not being provided on that date and that CNAs are responsible for documenting the care they provide.During a phone interview on 02/12/2026 at approximately 4:00 PM, Employee #32 (CNA), who no longer works at the facility, stated she worked only day shift, never night shift, and provided good care to her residents.During a phone interview on 02/13/2026 at approximately 9:30 AM, Employee #33 (CNA) stated she documents all care on the kiosk. She stated that on 06/30/2025 the unit was short staffed and there were only three (3) CNAs on the floor. She reported that Resident #302 urinated twice and was already soaked at the beginning of her shift, that she changed the bed and provided care, and that the resident later had a bowel movement which she addressed before leaving. She stated, It is my fault that I didn't document the care I provided for the resident, but I provided the care.During a phone interview on 02/13/2026 at approximately 10:00 AM, Employee #31 (LPN) stated it is the responsibility of the nursing supervisor to ensure CNA documentation is complete and that when CNA documentation is missing for an entire shift for multiple tasks, she would agree the tasks were not done.During a phone interview on 02/13/2026 at approximately 11:25 AM, Employee #34 (LPN) stated CNAs have access to three computers on the unit to document care immediately after providing it. She stated if tasks are not documented the system flags them, and if a resident refuses care, staff document the refusal in a progress note. She stated she did not know why there was no documentation for Resident #302 on 06/30/2025.During a phone interview on 02/13/2026 at approximately 11:40 AM, Employee #35 (RN Supervisor), who worked as the nursing supervisor on 2-South on 06/30/2025, stated she oversees CNA task documentation and ensures tasks turn green in the facility electronic medical record, PointClickCare, system before staff leave. She stated CNAs often do not complete documentation due to short staffing and that 2-South has many total care residents. She stated she could not recall the specific events of 06/30/2025 and that if a resident refuses care, nursing documents the refusal.There was no documentation in the medical record to indicate Resident #302 refused care on 06/30/2025. There was no documentation to show the resident received toileting assistance, incontinence care, turning and repositioning, or personal hygiene during the night shift on 06/30/2025, as required by the care plan.The facility failed to ensure the resident #302 received necessary care services for the activities of daily living.

Based on observations, record review and staff interviews for two (2) of 65 sampled residents, it was determined that facility staff failed to follow physician orders for the use of floor mats while in bed to minimize fall related injuries for one (1) resident; and failed to follow physician orders when providing wound care for one (1) of three (3) sampled residents receiving wound care. Residents' #95 and #285. Resident #95 was admitted to the facility on [DATE] with multiple diagnoses that included: Difficulty Walking, Muscle Weakness, Severe Anemia and Fibromyalgia. A care plan dated 02/04/25 documented, in part: Focus: [Resident #95's name] had a fall in her room sustaining a swelling with open area on her right forehead . Interventions: Floor mats to both sides of bed when resident is in bed to minimize fall related injuries . A physician order dated 02/07/25 documented, Fall precaution every shift. A physician order dated 02/09/25 documented, Bed in lowest position when resident is in bed to minimize fall related injuries .Floor mats to both sides of the bed when resident is in bed to minimize fall related injuries every shift. A nursing progress note dated 02/09/2025 07:41 [7:41 AM] documented, in part: S/P (status post) fall day 3/3 (third day of 3 days) . floor mat on both sides of her bed. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that facility staff coded a Brief Interview for Mental Status (BIMS) summary score of '15,' indicating that the resident was cognitively intact. Functional mobility that included: Dependent for Sit-to-lying; Lying-to-sitting; Chair/bed-to-chair transfers and Sit-to-stand that documented: not attempted due to medical condition or safety concerns. During an observation conducted on 01/29/26 at 10:15 AM it was revealed that the resident was in bed and there were no floor mats in place on the right and left side of the bed. During a face-to-face interview conducted on 01/29/26 at 10:20 AM Employee #11 (Certified Nursing Assistant) stated, I don't know about that, you have to ask the unit manager about floor mats. During a face-to-face interview conducted on 01/29/26 at 10:23 AM Employee #12 (Registered Nurse) stated, This is my first time working with her [Resident #95], I haven't been in the room yet. During a face-to-face interview conducted on 01/29/26 at 10:25 AM Employee #7 (Unit Manager) stated, I'm not sure about the floor mats, I will check when they are done with ADL (activities of daily living) care. During a face-to-face interview conducted on 01/29/26 at 1:00 PM Employee #3 (Director of Nursing) acknowledged the findings and stated, You were right, I checked the orders and the care plan, and the floor mats should've been there [on each side of the resident's bed]. 2. Resident #285 was admitted to the facility on [DATE]. The resident has a history of Pressure Ulcer and Dysphagia. A physician order dated 11/13/25 instructed, Right Heel: Cleanse with wound cleanser, pat dry, apply betadine, and leave open to air. Two times a day for wound care. A quarterly Minimum Data Set assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status summary score of 3 indicating sever cognitive impairment. The resident was also coded for being dependent on staff for activities of daily living and having one Stage 4 pressure ulcer and one unstageable pressure ulcer. A care plan with a review date of 12/12/25 documented in part, Focus- [Resident's name] has an actual pressure ulcer development of Sacrogluteal and [unstageable pressure ulcer]to right heel related to limited mobility. Interventions- Administer wound treatment as ordered by MD/NP (medical doctor/nurse practitioner). A physician order 12/25/25 instructed Sacrogluteal: Cleanse the wound with wound cleanser, pat dry, and apply Collagen, Calcium Alginate, and Zinc Oxide Paste to the periwound. Cover with a silicone-bordered superabsorbent. A wound assessment report dated 01/07/26 documented in part, Location [#1]: Right heel. Measurement- Length: 1.00 cm, Width: 1.90 cm L x W: 1.90 cm2 Depth: 0.30 cm. Observation- Etiology: Pressure Ulcer/Injury, Stage/Severity: Unstageable, 100% eschar. Location [#2]: Sacrogluteal.Measurements- Length: 4.30 cm Width: 5.00 cm L x W: 21.50 cm2 Depth: 0.30 cm.Observation- Etiology: Pressure Ulcer/Injury Stage/Severity: Stage 4. 30% epithelial,70% granulation, Periwound: Fragile, Intact, Scarring, Non-blanchable maroon discoloration. An observation on 01/16/26 at approximately 11:30 AM showed the following: Employee #4 (LPN/Wound Nurse) used normal saline to clean the resident's right heel and sacrogluteal wound. Additionally, the employee failed to apply zinc oxide to the periwound of the sacrogluteal wound. She did however apply zinc oxide to the resident's buttocks. After observation, the employee stated that she did not use wound cleanser to cleanse the resident's wounds because it was not available. The employee did not explain why she did not apply zinc oxide to the periwound of the resident's sacrogluteal wound. During a face-to-face interview on 01/16/26, Employee #3 (DON) stated that the facility did have wound cleanser and the employee should have used it to cleanse the resident's wounds. The employee also said that Employee #4 should have applied zinc oxide to the periwound of the resident's sacrogluteal wound as prescribed. It should be noted that the DON showed the surveyor a bottle of wound cleanser.

Number of residents sampled: Number of residents cited: 685Based on record review and staff interview facility staff failed to ensure residents received treatment and care in accordance with professional standard of practice for services to maintain his eye vision as evidence by Follow up visit with the Ophthalmologist in one year was not completed. Resident #11Finding includes .Resident #11 was admitted to facility on 08/25/2017with diagnosis anemia, Polyneuropathy, Atherosclerotic Heart Disease, Peripheral Vascular Disease, HIV, Presbyopia and Dry eye Syndrome of Bilateral Lacrimal Gland.Resident #11 requested by the surveyor I want to see the Ophthalmologist.A review of Ophthalmologist report dated 12/31/2021 showed residents. to follow up visit in one year.A review of Nurses progress and Ophthalmologist consult notes showed no documentation of the resident follow up visit to the ophthalmologist within one year for services for his vision care. This indicates that the resident has not been seen by an Ophthalmologist in 4 years.The evidence showed resident #11 last Ophthalmologist visit was dated 12/31/2021, indicating 4 years ago.A face-to-face interview conducted on 02/13/2026 at approximately 10am with Employee #3 [Director of nursing] who was made aware of concerns that the resident missed his 1 year follow up visit with ophthalmologist that now indicates the resident has not seen the Ophthalmologist in 4 years. Findings were acknowledged and an appointment was made for residents to see in- house Ophthalmologist. [NAME], [NAME] (11) [NAME]-Sampong, [NAME] (27513) - Comm-Sensory No NotesCANNING, [NAME] (11) [NAME]-Sampong, [NAME] (27513) - RESIDENT NOTE No Notes

Based on observations, record review and staff interviews for one (1) of 65 sampled residents, it was determined that facility staff failed to ensure that extra tracheostomy supplies were available at the bedside for a resident who is tracheostomy dependent. Resident #17. The findings included:A facility policy titled 'Tracheostomy Care' with a review date of 06/26/2025 documented, in part: 3b. Maintain a suction machine, a supply of suction catheters, correctly sized cannulas, and an ambu [manual resuscitator] bag easily accessible for immediate emergency care. A review of Resident #17's medical record revealed: Resident #17 was admitted to the facility on [DATE] with multiple diagnoses that included: Respiratory Failure with Hypoxia, Tracheostomy Dependent, Aphasia and Seizure Disorder. A care plan dated 10/10/25 documented, in part: Focus: [Resident #17's name] has trach (tracheostomy) sz (size) 6 Shiley, sz 6.5 TC (tracheostomy collar) . Interventions: Keep extra trach tube and obturator at bedside. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 'Severely Impaired.' Dependent on staff for all Activities of Daily Living care; Dependent on Respiratory Treatments to include oxygen therapy, suctioning, tracheostomy care and Invasive Mechanical Ventilation. A physician's order dated 02/02/26 documented, Back-up trach (tracheostomy) at bedside. Size #6 uncuffed every shift. During an observation conducted on 02/12/26 at approximately 3:50 PM, there was not a back-up tracheostomy tube size six (6) uncuffed, or obturator at the resident's bedside. During a face-to-face interview conducted on 02/12/26 at approximately 3:52 PM Employee #39 (The assigned Licensed Practical Nurse) was asked where the back-up tracheostomy tube was kept. She proceeded to look around the resident's bedside to locate the back-up tracheostomy tube, but was unsuccessful and then stated, I've worked with her [Resident #17] a few times, but it never come to my mind to check for the extra supplies. During a face-to-face interview conducted on 02/12/26 at approximately 3:55 PM Employee #27 (Unit Manager) was asked where the back-up tracheostomy tube was kept. She also proceeded to look around the resident's bedside to locate the back-up tracheostomy tube, but was unsuccessful, then left the resident's room. Employee #27 returned to the resident's room with a clear plastic bag that contained a pack of 4 x 4 Gauze sponges, a roll of white surgical tape and a pair of green bandage scissors. When Employee #27 was asked about the back-up tracheostomy tube and the size of the tube, she had no comment. During a face-to-face interview conducted on 02/12/26 at approximately 4:05 PM Employee #3 (Director of Nursing) acknowledged the findings and stated, The extra trach supplies must always be at the bedside for emergencies and should include the trach and correct size lumen.

Based on record review and staff interviews, for one (1) of 65 sampled residents the facility staff failed to ensure nursing staff functioned with the appropriate competencies and skills to provide nursing and related services to assure resident safety as evidenced by the nurse's administration of a significant medication error. Resident #317 The findings included: Resident #317 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Dependence on Dialysis, Type 2 Diabetes Mellitus, End-Stage Renal Disease, Cerebrovascular Accident (Stroke), Dysphonia, and Need for Assistance with Personal Care. A review of Resident #317's medical record showed: A care plan initiated on 04/30/2025 that documented: [Name of Resident #317] has vision impairment/hearing impairment r/t (related to) blindness in the right eye and deafness in the left ear. Goal: [Name of Resident #317] will maintain optimal quality of life within limitations imposed by visual function through the next 90 days. Target Date: 08/21/2025; Interventions.Review medications for side effects which affect vision. An admission minimum data set (MDS) assessment dated [DATE] that documented that Resident #317 had moderate difficulty with hearing, severely impaired vision, and had a Brief Interview for Mental Status (BIMS) Summary Score of 15, indicating that the resident had intact cognition. A physician's order with a start date of 06/10/25 at 8: 00 AM that directed: Debrox Solution 6.5% (Carbamide Peroxide) Instill 5 drops in right ear two times a day for ear impaction for 4 Days. A physician's order with a start date of 06/12/25 at 9:00AM that directed: Artificial Tears Ophthalmic Solution 0.2- 0.2-1 % (Glycerin-Hypromellose Polyethylene Glycol 400), Instill 2 drops in right eye three times a day for Redness for 1 Week. A physician's order with a start date of 06/12/25 at 9:00AM that directed: Artificial Tears Ophthalmic Solution 0.2- 0.2-1 % (Glycerin-Hypromellose Polyethylene Glycol 400), Instill 2 drops in right eye three times a day for Prophylaxis for 1 Week. A June 2025 Medication Administration Record (MAR) for Resident #316, which showed that facility staff administered Debrox Solution 6.5 % (Carbamide Peroxide) to the Resident on 06/10/25 and 06/11/25. Of note, further review of the June 2025 MAR showed that there were no eye medication or treatment orders for the Resident scheduled before 06/12/25 at 9:00 AM. A facility reported incident submitted online on 06/12/25 at 4:51 PM that documented: Initial Report: Nurse reported that she administered medication via the wrong route. Resident assessed by RN (Registered Nurse). No signs of adverse effect. [The] Physician and [the] resident [were] made aware. Investigation initiated. A review of the facility's investigation documents for the incident revealed the following: A typed statement that documented: 6/11/2025.Interviewer: [Name of Employee #16 /RN/Educator/Former Executive Clinical Director]; Statement of Employee #17/RN assigned to Resident #317]: '[Name of Resident #317] requested her medication. After giving her medication, she reported that her eye was stinging. I immediately rinsed her eye. She did not report any additional discomfort. I left the room and yelled for the supervisor. I notified the supervisor that I had mistakenly put an ear drop in [Resident #317]'s eye. 2. A written statement by Employee #15 (RN Supervisor) that documented: At about 5:00 PM, the nurse reported that she administered an ear drop to the right eye. The resident said, 'As soon as the nurse dropped the eye drop into my right eye, I felt a little bit stinging in my eye, and I told the nurse.' DON assessment. Resident [317] denied pain in the right eye. Eye flushing was done. No adverse reaction noted. [The] RMD (the resident's medical doctor) was notified, and an order was given to flush eye q (every) 2 hrs (hours) for 4 days, Artificial tears 2 drops to right eye TID (three times a day) x 1 week for prophylaxis. 3. A final report for the facility's investigation submitted to the State Agency on 06/12/25 at 11:52 AM that documented in part: Final Report: .On June 11, 2025, [Name of Employee # 17/Registered Nurse (RN) for Resident #317] reported that she administered medication via the wrong route. As a result of the report, an investigation was initiated. [Resident #317] was assessed by the RN supervisor, and there were no signs of adverse effects. [Resident #317] did not report any discomfort to the supervisor. The physician and the Resident were also made aware. -The nurse who gave the medication was interviewed. Her medication administration competency was also reviewed. Employees #16 and #17 no longer work at the facility and were not available for interview during the survey. Employee #18 was on leave and unavailable for interview during the survey. Of note, Resident #317 left the facility AMA (against medical advice), on 06/11/25, the same day as the incident, and was unavailable for interview. During a face-to-face interview on 01/30/26 at 3:35 PM, Employee #15 (Unit Manager/Supervisor) when asked if agency nurses were checked for medication administration competency before working with residents on the unit, she stated, There is a competency checklist sheet for new and agency nurses on all units and if there was a problem they would be re-educated by [Name of Employee #16/ Educator, Clinica; We used to also do audits of nurses for med pass. The audit sheets were given to Employee #16. During a face-to-face interview on 02/08/26 at 3:03 PM, Employee #3/Director of Nursing (DON),when asked whether agency nurses receive an orientation that includes observation and competence in medication administration before working with residents, she stated, They do now- at least five random medication administration (med pass) observations are conducted weekly by either the new educator or me. When asked whether she documented the med pass observations, she stated that she did and would check whether there were any med pass observations for Employee #17 after the Employee's orientation on 11/27/24. After reviewing her records, the DON stated that she did not see med pass observations for Employee #17 and could find no other medication administration training for the Employee after her initial orientation. She further commented that Employee #17 was an agency nurse and that, after the incident with Resident #317, she was never asked to return.

Number of residents sampled: Number of residents cited: Based on observation, record review, and staff interviews, the facility staff failed to establish a consistent location for the pharmacist's monthly medication review recommendations for each resident, thereby ensuring that the pharmacist's findings were available for review upon request. Resident #8 The findings included: Resident #8 was admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus, Epilepsy, Hypertension, Bipolar Disorder, Schizoaffective Disorder, Viral Hepatitis C, and Generalized Muscle Weakness. A review of Resident #8's medical record showed: A Quarterly Minimum Data Set (MDS) assessment dated [DATE], which documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of 15, indicating that Resident #8 had intact cognition. In addition, the assessment documented that the Resident had received the following medications during the last 7 days of the assessment: a hypoglycemic (including insulin), an antipsychotic (on a routine basis), an antiplatelet, and an anticonvulsant. An order dated 06/01/22 at 9:00 AM that directed: Haldol Decanoate Solution 50 mg/ml (milligrams/milliliter) (Haloperidol Decanoate) Inject 1 ml intramuscularly one time a day starting on the 1st and ending on the 1st every month for Schizoaffective Disorder.An order dated 06/01/22 at 9:00 AM that directed: Haldol Decanoate Solution 50 mg/ml (Haloperidol Decanoate) Inject 1 ml intramuscularly one time a day starting on the 19th and ending on the 19th every month for Schizoaffective Disorder. An order dated 06/17/24 at 2:09 AM that directed: Ammonia level every Friday one time a day every Fri (Friday) for high ammonia level. An order dated 12/22/24 at 8:00 AM that directed: Lantus SoloStar 100 unit/ml Solution pen-injector Inject 25 units subcutaneously two times a day for DM (Diabetes Mellitus). Hold if BS (Blood Sugar) is less than 120. An order dated 03/28/25 at 2:45 PM that directed: Obtain resident Depakote level on Wednesdays every 6 months. in the morning every 6 month(s) starting on the 16th for 1 day(s).An order dated 06/14/25 at 8:00 AM that directed: Novolog Flexpen 100 unit/ml Solution pen-injector. Inject as per sliding scale: if 0-200 = 0 units; 201-250 = 2 units; 251-300 = 4 units; 301-350 = 6 units; 351-400 = 8 units, subcutaneously before meals for DM (Diabetes Mellitus). Call the MD (Medical Director) if less than 60 and greater than 400. An order dated 06/15/25 at 8:00 AM that directed: Novolog Solution 100 units/ml. (Insulin Aspart). Inject 12 units subcutaneously before meals for Diabetes Mellitus. An order dated 11/11/25 at 8:00 AM directed: Depakote Oral Tablet Delayed Release 500 mg (Divalproex Sodium) Give 1 tablet by mouth two times a day for Bipolar Disorder.A review of Resident #8's entire paper chart showed the following monthly pharmacy recommendations documents, entitled, Consultant Pharmacist Non-Physician Comment/ [Name of Consultant Pharmacy Agency] Non-Physician Report: 1. January 5, 2025.Resident: [Name of Resident #8]; Physician: [Name of Medical Director]; Comment:12/27 NH3 (Ammonia level) 62; Nurse Signature: [signed and dated by (Employee #/RN Supervisor) on 01/06/25. 2. January 5, 2025.Resident: [Name of Resident #8]; Physician: [Name of Medical Director]; Comment: No irregularities noted. Nurse Signature: [signed and dated by (Employee #/RN Supervisor) on 01/06/25. 3. May 5, 2025: Resident: [Name of Resident #8]; Physician: [Name of Medical Director]; Comment: 4/16 VPA (Valproic acid level) = 41, for mood disorder; Nurse Signature: [signed and dated by (Employee #3/DON) on 06/09/25. Further review of the Resident's paper and electronic medical records showed that there was no documented evidence of the pharmacist's recommendations or monthly medication review for Resident #8 from 01/05/25 to 05/05/25 and from 05/05/25 to 12/31/25. During a face-to-face interview on 01/29/25 3:56 AM, Employee #5 (Registered Nurse/# South Unit Manager), when asked where the pharmacist's monthly medication review recommendations (MMRs) for Resident #8 were kept, she stated, while searching through the Resident's paper chart, They should be in each resident's paper chart. I know the DON (Director of Nursing) gets them via email from the pharmacist monthly, and she disperses them to the Unit Supervisors so they can be placed in the resident's chart where the physician can see/sign them. Employee #38 then showed the surveyor the three MMRs that the surveyor had previously reviewed from Resident #8's paper chart. When asked where the pharmacist's recommendations were for the other months in 2025, the Employee made no further comment.

Based on observations, record reviews, and staff interviews for two (2) of 65 sampled residents, the facility staff failed to ensure that food services accommodated one (1) resident's allergy to eggs and personal preferences for two (2) residents. Residents #89 and #67). Resident #89 was admitted to the facility on [DATE] with diagnoses that included Spinal Stenosis, Type 2 Diabetes with Hyperglycemia, Discitis, End Stage Renal Disease, and Weakness. A review of Resident #89's medical record revealed the following: A physician's order dated 02/21/25 that stated: LCS/NAS (low concentrated sweets/no added salt) diet, regular texture, thin liquids consistency. A History and Physical assessment dated [DATE] at 12:00 AM that documented: .C . 2.Meds .Allergies: aspirin, codeine, and eggs. A comprehensive Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) Summary Score of 14, indicating that the resident had intact cognition and the resident had a therapeutic diet (e.g., low salt, diabetic, low cholesterol). A comprehensive care plan, revised 01/13/26, lacked documented evidence that the resident's preference for double portions and his egg allergy were addressed. During a face-to-face interview on 02/09/26 at approximately 10:15 AM, Resident #89 asked, Who do I talk to about my meals from this past weekend? I don't know why they (facility staff) can't get my food right. They keep sending me eggs at meals, and I have an allergy to eggs, and they are not sending me double portions. I am supposed to get double portions. The resident then stated I have taken pictures as evidence, and I have called down to the kitchen and spoken with [Director of Kitchen Services] myself on several occasions. During a face-to-face interview on 02/09/26 at 3:46 PM with Employee # (Food Services Manager) stated, We have 14 staff members including a supervisor or assistant who check meal trays before they go up to the residents on the floor. Before placing the meals in the meal cart the loader receives the tray, takes the cover off of each tray, double checks it, puts the cover back on the tray and places the tray in the cart. We have 70 or more residents who receive double portions of one type or another. The Employee reviewed Resident #89's photos and stated, I am not sure what happened there, and the Employee acknowledged the finding. 2. Resident #67 had diagnoses that included spinal stenosis (cervical region), quadriplegia, central cord syndrome, type 2 diabetes mellitus with diabetic peripheral angiopathy, major depressive disorder, and hypertension. The resident was assessed as alert and oriented, able to communicate needs, and required assistance with activities of daily living. The resident had a physician's order for a regular diet with regular texture and thin liquids. No known food allergies were documented. On 01/16/2026 at approximately 11:00 AM, Resident #67 was observed in his room, alert and oriented in no apparent distress; at approximately 1:45 PM, Resident #67 complained he had not yet received his lunch. The resident added that the previous day he had ordered a cheeseburger from the Always Available Menu but did not receive it. The resident stated, Normally my food comes with everyone else on the floor. On 01/29/2026 at approximately 1:55 PM, a nurse delivered a lunch tray to Resident #67's room. The tray contained cheeseburgers from the kitchen. A review of Food and Nutrition Services progress notes dated 11/04/2025 documented the resident remained on a regular diet and had multiple food preferences and requested access to regular diet for greater choices. A review of nursing progress notes dated 01/12/2026 documented the resident was to receive a chicken and beef dinner for the evening meal. The note indicated the resident disliked chicken being served as a standing order for baked chicken. The dietary department was contacted and offered a substitute of a grilled turkey and cheese sandwich with mayonnaise. The resident declined the substitute. A review of the facility tray line ticket for Unit 2-South, where Resident #67 resided, indicated lunch serving time was scheduled at 12:30 PM with delivery time at 12:45 PM. Observation revealed Resident #67 did not receive lunch until approximately 1:55 PM. A review of the undated Prestige Always Available menu, posted on the wall in the resident's room, listed a Prestige Prime Cheeseburger – premium handcrafted beef infused with signature flavors, topped with cheddar cheese and gourmet accompaniments, served on a toasted bun, as an item available for residents to order as an alternative to the regular menu. On 02/09/2026 at approximately 1:45 PM, Employee #27, the 2-South Unit Manager, stated that Resident #67's cheeseburger was not sent with the unit's meal trays and that a nurse had to go to the kitchen to obtain the tray after the initial meal pass. On 02/09/2026 at approximately 2:35 PM, Employee #20, the Food Service Director stated staff were not aware that the cheeseburger was unavailable for the resident on the previous day, 02/08/2026, and reported that if an item is listed on the Always Available Menu, it should be provided unless contraindicated by the resident's diet order or allergies. During a phone interview on 02/09/2026 at approximately 4:15 PM, Employee #37, CNA, stated that the employee who took the order stated that when the order was placed the previous day (02/08/2026) at approximately 10:30 AM, the kitchen staff reported cheeseburgers and hotdogs weren't available. During a phone interview on 02/10/2026 at approximately 9:30 AM, Employee# 20, the Food Service Director stated the kitchen had cheeseburgers available but did not have buns to serve the sandwich as ordered on 02/08/2026. During a phone interview on 02/10/2026 at approximately 10:00 AM, Employee #37 stated the employee who took the order reported hotdogs and cheeseburgers were not available; I was not told it was only the buns that were not available. The facility failed to ensure Resident #67 received his meal at the scheduled mealtime; ensure the availability of a menu substitute listed on the Always Available Menu. And this resulted in Resident #67 receiving his lunch tray more than one (1) hour) late after the scheduled delivery time and not receiving the requested menu item on the prior day.

Number of residents sampled: Number of residents cited: Based on residents' interviews, observation, and staff interviews, the facility staff failed to ensure residents received pm snacks. The findings included:A policy titled, Offering/Serving Bedtime Snacks with a review date of 08/15/25 instructed nursing staff to offer bedtime snacks to residents in accordance with resident's needs, preferences and requests on a daily basis.During the task of Resident Council meeting on 01/14/26 starting at 2:43 PM held with multiple residents from different units in the facility stated that they are not provided with pm snacks. Additionally, Resident #10 stated that they do have pm snacks for specific residents and their names are on the snack. The resident said that he can only get a pm snack if the resident who it is assigned to refuses it. During observations of kitchen on Unit 1 south and 3 south on 01/15/26 starting at 10:30 AM revealed multiple sandwiches with residents' names.During a face-to-face interview with the Administrator and Executive Director on 01/15/26 at approximately 3PM they stated that they were not aware of residents not being offered pm snacks. They have corrected the issues and now multiple pm snacks are provided for all units for all residents.

Number of residents sampled: Number of residents cited: Based on observations and staff interviews, facility staff failed to prepare and distribute foods under sanitary condition, as evidenced by the following observations. The findings include:During a walkthrough survey in the kitchen on 01/06/2025 approximately at 9:30AM, the following observations were made: Cleaned and sanitized food contact utensils stored on rack that had no minimum 6 inches clearance from floor to prevent potential contamination at the manual dish washing area in the kitchen. There was no proper test kit provided to monitor food contact surface sanitizing solution concentration at the 3-compartment sink manual dish washing and for the sanitizing buckets. Single use coffee cups and lids left on floor under coffee making station. Food service director, Employee #20, was immediately made aware of these findings and proceeded to implement measures to address these issues.During a face-to-face interview on 01/06/2026, approximately at 10:00 AM, the above observations were acknowledged by Employee #20, Food Service Director.During kitchen survey on 01/12/2026 approximately at 9:40 AM, it was observed that:Mashed potatoes were held at improper hot holding temperature, 134-degree F, 132-degree F on the broken steam table.Kitchen utensils were not properly washed, rinsed and finally sanitized in the 3-compartment sinkSame spatula used to handle raw and cooked hamburgers on griddle; this practice created cross contamination; affected food items were discarded at callFood service director, Employee #20, was immediately made aware of these findings and proceeded to implement measures to address these issues.During a face-to-face interview on 01/12/2026, approximately at 9:40 AM, the above observations were acknowledged by Employee #20, Food Service Director.During kitchen survey on 01/13/2026 approximately at 2:00 PM, it was observed that mashed potatoes were held at improper hot holding temperature, 123-degree F, 120-degree F.During a face-to-face interview on 01/13/2026, approximately at 2:00 PM, the above observations were acknowledged by Employee #20, Food Service Director.

Based on record reviews and staff interviews for two (2) of 65 sampled residents, it was determined that facility staff failed to show documented evidence that the facility's visitor logbook was retained with accuracy and documentation of gastrostomy management was lacking for one resident. (Residents #55 and #220). The findings included: Resident # 55 was admitted to facility on 04/03/2025 with diagnosis of diabetes mellitus, myocardial infarction, fluid overload, hypertension, osteoarthritis and congestive heart failure. Resident #55 reported to facility staff that on 04/07/2025, two hundred (200) dollars was missing from his room. He was residing on unit 2 South when this happened. On 02/06/2026 at 1:12 PM during an interview with Resident #55, in response to an inquiry regarding how he obtained the 200 dollars, he stated, my cousin [name] visited and gave it to me. A review of the visitor's logbook for 2south where the resident resided at the time showed that the pages were missing for the dates during the period of 04/01/2025 through 04/029/2025. Interviews were conducted on 02/12/2026 with the staff assigned to Resident #55 on 04/07/2025, Employees #26 and # 36. The staff stated that they were not aware the resident had $200 until it was reported missing. In response to an inquiry regarding the process for securing resident valuables (e.g. money), they stated it would be reported to the registered nurse who would secure it in a safe. The evidence showed that facility staff failed to ensure accuracy and retention of the visitor logbook. A face-to-face interview was conducted with Employee #3 [Director of Nursing] on 2/12/2026 at 2:00pm, she acknowledged the visitor logbook was missing pages from 04/01-04/29/2026 and she was unable to locate the missing pages. 2. A facility policy titled 'Documentation in Medical Record' with a review date of 08/14/2025 documented, in part: Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. 1. Licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medial record in accordance with sate law and facility policy. 2. Documentation shall be completed at the time of service, but no later than the shift in which the assessment, observation, or care service occurred. 3. Documentation may be performed manually or as per the facility's specific electronic medical record software program. A review of Resident #220's medical record revealed: Resident #220 was admitted to the facility on [DATE] with multiple diagnoses that included: Stroke, Dysphagia, Gastrostomy Tube, Dementia and Seizure Disorder. An Annual Minimum Data Set (MDS) assessment dated [DATE] documented: facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 'Severely Impaired'; Functional Abilities: Totally Dependent on staff for all ADLs (activities of daily living) and transfers; and the resident had a Gastrostomy Tube for feedings. A physician's order with a start date of 08/09/24 documented, Dressing Change to G-(Gastrostomy) tube site every night shift in the morning. A physician's order with a start date of 08/10/24 documented, Enteral Feed Order: In the morning change flush syringe every 24 hours. A review of Resident #220's Treatment Administration Record dated 02/01/25 – 02/28/25 revealed no documented evidence that the resident's Dressing change to his G-tube site was completed on 02/10/25 at 6:00 AM as ordered by the physician. A review of Resident #220's Medication Administration Record dated 02/01/25 – 02/28/25 revealed no documented evidence that the resident's G-tube flush syringe was changed on 02/18/25 at 6:00 AM as ordered by the physician. A face-to-face interview conducted on 01/23/26 at 12:25 PM Employee #3 (Director Of Nursing) acknowledged the findings and stated, I cannot vouch for what wasn't done, I can only provide Education on proper documentation.

Number of residents sampled: Number of residents cited: Based on observations, record review, and staff interviews for one (1) of 65 sampled residents, the facility staff failed ensure no breaks in infection control by failing to wear proper personal protective equipment while providing incontinent care for a resident on Enhanced Barrier Precautions (EBP). Residents #3 The findings included: A facility policy entitled, Enhanced Barrier Precautions (EBP), reviewed and revised on 06/26/25, that documented: .Definitions: Enhanced Barrier Precautions (EBP): refer to an infection control intervention designed to reduce transmission of multidrug -resistant organisms that employ targeted gown and glove use during high contact resident care activities. Policy Explanation and Compliance Guidelines: 1. Prompt recognition of need: a. All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.3. Implementation of Enhanced Barrier Precautions: .b. PPE (personal protective equipment) for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room.4. High-contact care activities include a. Dressing, b. Bathing, c. Transferring, d. Providing hygiene, e. Changing linens, f. Changing briefs or assisting with toileting, g. Device care or use. h. Wound care: any skin opening requiring a dressing. Resident #3 was admitted to the facility on [DATE] with diagnoses that included:Idiopathic Aseptic Necrosis of Left Femur; Gout; Methicillin-Resistant Staphylococcus Aureus (MRSA) Infection; Bacterial Infection, Unspecified; Hidradenitis Suppurativa; Complications of Colostomy; Protein Calorie Malnutrition, and Need for Assistance with Personal Care. During an observation on 01/08/26 at 1:04 PM, Resident #3 was lying in bed watching television. The Resident stated that his brief was wet and he needed to be changed. The Resident pressed his call light for his nurse or CNA (Certified Nurse Aide). At approximately 1:10 PM, Employee #16 CNA) washed his hands and applied (donned) gloves, per the facility's EBP policy. The Employee did not apply a gown, as required by policy. The Employee removed the changed the Resident's brief and applied cream per the physician's orders. Employee #16 removed (doffed) his gloves per facility policy and washed his hands before exiting the Resident's room. Of note, hanging on the resident's room door, was a storage bag with compartments that held disposable gloves, masks, and gowns. In addition, there was a sign posted on the Resident's door indicating that the resident was on enhanced barrier precautions. The sign directed all staff performing any high-contact care activity to apply gloves, a mask, and a gown before entering the Resident's room. A review of Resident #3's medical record revealed: A physician's order dated 11/02/25 at 8:58 PM that directed: Barrier cream to buttocks for protection every shift. A physician's order dated 11/02/25 at 9:02 PM, that directed: Change Resident['s] colostomy bag q (every) shift as needed every shift related to Other Complications of Colostomy. A physician's order dated 11/02/25 at 9:02 PM that directed: Colostomy Care; Ostomy; Remove soiled appliance. Cleanse the stoma and peristomal skin with saline gauze or a moist washcloth. Do not use soap or lotions on the stoma. Place a wafer around the stoma and attach the corresponding pouch. Empty when 1/3, 1/2 full. Change every 3 days and PRN (as needed) when leaking. every day shift every 3 day(s). A physician's order dated 11/16/25 at 11:00 PM that directed: Aquaphor Advanced Therapy External Ointment (Emollient) Apply to urinary fistula topically every shift for skin protection, apply to the surrounding area. A physician's order dated 12/25/25 at 3:25 PM, that directed: Left groins: Cleanse with wound cleanser, pat dry and apply calcium alginate with silver, mesh underwear, superabsorbent qd/prn (every day as needed). One time a day for wound treatment until seen and evaluated by the wound team. A physician's order dated 01/13/26 at 12:25 AM that directed: Right groins: Cleanse with wound cleanser, pat dry and apply calcium alginate with silver, mesh underwear, superabsorbent qd/prn, one time a day for wound treatment. During a face-to-face interview on 01/08/26, approximately 1:15 PM, Employee #16 stated that Resident #3 was on Enhanced Barrier Precautions because he had a colostomy and wounds. When asked why he had not put a disposable gown on before entering the room to provide incontinent care, he stated, I don't know, I just forgot. The Employee then acknowledged the findings.

Number of residents sampled: Number of residents cited: Based on observations and staff interviews, the facility staff failed to maintain essential kitchen equipment in good working condition as evidenced by the following:The findings include:During the initial walkthrough survey in the kitchen on 01/06/2026, the following observations were made: One (1) of one (1) the reach-in refrigerator in kitchen located next to the ice making machine was leaking condensate water inside its food storage chamber,The refrigerator referenced in above item #1 was missing light bulb cover inside its food storage chamber,Dish washing machine area - the spray hose storage hook was in poor repairDish washing machine area - atmospheric backflow preventer valve cover was in poor repairBroken garbage disposer attached underneath a food preparation sinkLeaking drainpipe under the food preparation sink at the cooklineThe ventilation exhaust hood in kitchen was missing grease trap pan and one grease filterFood service director, Employee #20, was immediately made aware of these findings and proceeded to implement measures to address these issues.During a face-to-face interview on 01/06/2026, approximately at 10:00 AM, the above observations were acknowledged by Employee #20, Food Service Director.During kitchen survey on 01/12/2026 approximately at 9:40 AM, it was observed that the steam table was not operational; mashed potatoes were held at improper hot holding temperature, 134-degree F, 132-degree F on then broken steam tableFood service director, Employee #20, was immediately made aware of these findings and proceeded to implement measures to address these issues.During a face-to-face interview on 01/12/2026, approximately at 9:40 AM, Employee #20, Food Service Director, stated that the steam table went out of operation yesterday (01/11/2026) approximately at 3:00 PM. He added and said, order for part to fix the table is already submitted, repair is anticipated today. During kitchen survey on 01/12/2026 approximately at 4:45 PM, the following observations were made: the steam table was still not operational, and kitchen employees were plating dinner for residents on the broken steam table.During a face-to-face interview on 01/12/2026, approximately at 4:45 PM, Employee #20, Food Service Director, acknowledged the above observations and further stated maintenance crew came and looked at the table today, and they said they will be back tomorrow to continue working on the table.During a face-to-face interview on 01/13/2026, approximately at 9:00AM, Employee #20, Food Service Director, stated that the part for the broken steam table was delivered and the crew would fix the table today.During kitchen survey on 01/13/2026 approximately at 2:00 PM, it was observed that mashed potatoes were held at improper hot holding temperature, 123-degree F, 120-degree FDuring a face-to-face interview on 01/13/2026, approximately at 2:00 PM, Employee #20, Food Service Director, said one of the steam tables is fixed and operational now but the other one is still not functional and it will be fixed tomorrow.

Based on observations, record reviews, staff interviews and a resident's interview, for three (3) of nine (9) sampled residents, the facility failed to ensure residents were free from physical abuse as evidenced by: (1) The Administrative staff making the decision to place Resident #2 (new admission), who was known for physical aggressive behaviors toward other residents, in a room with Resident #1, who was also known for physical aggression against other residents and staff and sexual misconduct. Subsequently, on 06/08/24, Resident #1 and Resident #2 were involved in a physical altercation which resulted in Resident #2 sustaining a stab wound to his left leg; and (2) An altercation on 06/15/24 between Employee #9 and Resident #4 led to the employee throwing lemonade and ice in the resident's face. Residents' #1, #2, and #4. Due to these failures, an Immediate Jeopardy (IJ) was identified at 42 CFR S483.12 Freedom from Abuse, Neglect, and Exploitation (F600) on June 18, 2024, at 10:31 AM. The facility provided a plan of corrective action to address the immediate concerns on June 18, 2024, at 5:44 PM and it was accepted by the State Agency's survey team. After the plan was verified, the IJ was removed on June 20, 2024, at 5:25 PM while the survey team was onsite. After the removal of the immediacy, the deficient practice remained at actual harm at the scope and severity of a G. These failures resulted in actual harm to Resident #2 on 06/08/24, a stab wound to his left leg, that required stitches. The findings included: A review of the facility's Abuse, Neglect and Exploitation policy dated 01/04/24 documented, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written procedures that prohibits and prevent abuse and neglect of residents .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse. 1. Facility staff failed to ensure Residents #1 and #2 were free from physical. Background information for Resident #2: Resident #2 was previously admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia, Metabolic Encephalopathy and Muscle Weakness. A nursing progress note dated 10/01/23 at 6:30 AM documented, At about 6:30 AM, [Resident #2] pushed [Resident #3] in the hallway and slapped him on the right side of jaw. The charge nurse rushed and separated both residents. [Resident #2] noncompliant and non-cooperative, refused to open his door to speak to the police officer. Nurse Practitioner notified and recommendation for psych consult given for resident with aggressive behavior. A behavior progress note dated 02/19/24 at 11:17 AM documented, Writer observed resident walked into [Resident #3 s] room, opened the window curtain, set the room temperature to 80 degrees and took a pair of [Resident #3's] shoes back to his room. Writer called other staff for assistance, but resident refused to give back the shoes. [Resident #2] was cursing at multiple staff members and became very hostile and intimidating. Resident #2 stated, I don't know why he [Resident #3] is still alive. Resident repeated the statement more than two times. A behavior progress note dated 02/21/24 at 11:43 PM documented, Resident asked for a razor blades at around 10:55 PM, writer told him just to shave in the morning so CNA (Certified Nurse Aide) can assist or help him, but he said, I know where the razors are, I will get some. He went to the supply room, pushed the door and grabbed razors, nobody can stop him. A nursing progress note dated 03/04/24 at 9:59 AM documented, Writer was informed that [Resident #2] pushed [Resident #3] out of his wheelchair causing the resident to fall on the floor in the hallway. Police and Crisis support were informed. A physician's order dated 03/04/24 directed, Transfer resident to the nearest psych hospital for evaluation. Resident #2 was transferred out of the facility via FD-12 (application form used for the emergency admission of an individual in need of immediate psychiatric evaluation) on 03/05/24. Review of the medical record showed that Resident #2 was readmitted to the facility on [DATE] to unit 2 south, room [ROOM NUMBER] bed A. Background information for Resident #1: Resident #1 was admitted to the facility on [DATE], with multiple diagnoses that included Anxiety, Schizophrenia, and Depression. The facility's census tracking form showed that Resident #1 resided on unit 2 south, room [ROOM NUMBER] bed B since 09/06/23. A care plan revised on 12/27/23 documented, [Resident #1] is on 1:1 monitoring for allegations of inappropriate touching of a female resident. Interventions included provide 1:1 monitoring every shift. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) summary score of 15 indicating that had an intact cognitive function. Also, the resident was coded for physical behavioral symptoms (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) directed towards others, verbal behavioral symptoms (e.g., threatening others, screaming at others, cursing at others) directed towards others, rejection of care behaviors, and receiving antipsychotic medications on a routine basis. A physician ' s order dated 05/01/24 directed, Psych consult for aggressive behavior. A care plan dated 05/02/24, documented in part, Focus- Alleged physical aggression towards another resident while both residents were on LOA (leave of absence) on 05/01/24 . Interventions- continue with 1:1 monitoring .psych[iatric] consult to evaluate . A Psychiatric Mental Health Nurse Practitioner (PMHNP) note dated 05/03/24 at 2:01 PM documented, Date of Service: 5/3/24, Consultation Alleged Physical Aggression/Assault to Another Resident. The patient was seen in his room, 1:1 monitoring staff sitting by the door. He stated, While I was on LOA, I saw her (The alleged victim) at the bus stop and both of us were talking, and this led to a heated argument, and she started yelling and cursing me out and I cursed her out as well. I never touched her, she told me that she is going to teach me a lesson, and they [the facility ' s staff] called the police, and I was arrested. A care plan dated 05/16/24 documented in part, Focus- verbal aggression towards nursing staff, going around nursing station, attempted to pick up the hole puncher .Interventions - continue with 1:1 monitoring, staff de-escalated the situation . A PMHNP note dated 05/17/24 at 11:14 AM documented, Date of Service: 5/16/24: Consultation Alleged Verbal Altercation Aggression/Outburst, attempt to hit a facility staff and exposure/fondling his [male genitalia] sitting on the floor in the room. - The patient was seen in his room, 1:1 monitoring staff sitting by the door. He stated, I was standing by the door of my room and the staff came and was trying to force herself into my room and I told her she could not come in and she forced herself through anyway and went to my bathroom to check if I was smoking in the bathroom and she found nothing. I cursed her out because she was not listening and she should not have come into my room for any reason, I don't like her. He denied any attempt to hit the staff. The provider further asked him about being naked, sitting on the floor, and fondling his [male genitalia]. He stated I was in my room I took the diaper off because my [gonads] feel hot sometimes and I was not fondling with my [male genitalia]. He further endorsed sitting on the floor. Sequence of events: An Admission Summary for Resident #2 dated 06/06/24 at 10:37 PM documented: [Resident #2] readmitted [to unit 2 south, room [ROOM NUMBER], bed A] today from [Psychiatric Hospital Name]. Resident came into the facility ambulating at about 3:45 PM with his personal belongings. Resident refused complete physical assessment and skin assessment, refused weight and inventory of his personal belongings on admission. A care plan for Resident #2 dated 06/06/24 documented but not limited to, Focus - [Resident #2] had an episode of physical aggression towards another resident on 10/01/23. [Resident #2] had an additional episode of physical aggression against another resident on 03/04/24 .Interventions - hourly monitoring for 72 hours. Review of unit 2 south's Hourly Monitoring binder showed no documented evidence that Resident #2 was being monitored hourly from 06/06/24 to 06/09/24. A Nursing Progress Note for Resident #2 dated 06/08/24 at 10:57 PM documented, Resident to Resident Altercation: At about 6:45 pm a report was received from staff stating that this resident [Resident #2] was actively having a physical altercation with another resident [Resident #1]. When this writer arrived at the unit, [Resident #2] was observed in the hallway trying to go after [Resident #1] and a staff member was in front of him trying to talk him down from moving forward. At some point, the staff talked him down, and he went back to his room and closed the door. DC (District of Columbia) Metropolitan Police were called at 6:50 pm and the police, including EMS (emergency medical services), arrived at the unit at about 6:55 pm and [Resident #2] was in his room with the door closed. Police knocked at the door and brought [Resident #2] into the hallway and interviewed both residents separately. Resident (#2) was noted bleeding from his left leg but was unsure of where the bleeding was coming from. When paramedics found where the bleeding was coming from, he was quickly 6 transported to [Hospital Name] for evaluation and treatment . A Facility Reported Incident (FRI) for Resident #1, DC~12873, submitted to the State Agency on 06/08/24 documented, There was a physical altercation between [Resident #1] and [Resident #2]. DC Metropolitan police were called. [Resident #2] was taken to the hospital while [Resident #1] was arrested. Investigation was initiated. A FRI for Resident #2, DC~12874, submitted to the State Agency on 06/08/24 documented, There was a physical altercation between [Resident #1] and [Resident #2]. DC Metropolitan police were called. [Resident #2] was taken to the hospital while [Resident #1] was arrested. Investigation was initiated. A Hospital Discharge Summary for Resident #2 dated 06/08/24 documented: Seen today for stab wound of leg, laceration. A Nursing Note for Resident #2 dated 06/09/24 at 1:45 AM documented, Received a call from [Hospital Name] at 8:45 PM and was informed that the resident has 3 stiches underneath his left knee. At about 10:50 PM, the resident was brought in via stretcher. Resident refused nursing assessment. During a face-to-face interview on 06/12/24 at 2:50 PM, Employee #4 (PMHNP) stated that she has been providing psych services to Resident #1 monthly and as needed (after altercations). Resident #1 was on 1:1 for behavior issues and was not safe to be roommates with another resident who had behaviors issues. On 06/06/24, she came to assess Resident #2 in room [ROOM NUMBER] A and saw that his roommate was Resident #1. She had safety concerns about Resident #1 and #2 being roommates. After evaluating Resident #2, she asked [Employee #7/ Unit 2 South's Unit Manager] why those two residents were put in the room. At which time, the unit manager informed her that she had nothing to do with the resident ' s room assignment, that decision was made by the Administration. During a face-to-face interview on 06/12/24 at 3:40 PM, Employee #8 (External Marketing Liaison/Admissions Department) stated that she was not a nurse, nor did she have a clinical background. She has been covering for the Admission's Director for the last 3 to 4 months. The resident ' s placement to a room is based on the facility ' s availability of beds and on clinical compatibility, such as isolation. She makes the determination of the resident's room placement. This was the first time that she was not a part of a resident's admission. However, she was aware that the Administrator and DON were discussing Resident #2's return to the facility. On 06/06/24, the facility had two male beds available. During a face-to-face interview on 06/13/24 at 9:45 AM, Employee #5 (CNA) stated that around 6:45 PM, during dinner, he was in another room when he heard a staff member yelling for help. He ran towards the screams for help and when he got to room [ROOM NUMBER], he saw that Residents #1 and #2 were fighting. He saw Resident #2 with a meal tray in his hand, hitting Resident #1 over the head three times then the meal tray broke into two pieces. He got in the middle of them, and the other staff pulled Resident #1 to the nurse ' s station. Resident #2 went back inside the room and then came out of the room holding a knife in his right hand and one of Resident #1 ' s shoes. Resident #2 held the show up against the wall and stabbed it until in tore into shredded pieces and fell on the floor. Resident #2 went back into the room and blocked anyone from being able to enter. The police came and were able to enter the room after multiple attempts, talked to Resident #2, and found a knife. During a telephone interview on 06/13/24 at 10:54 AM, Employee #6 (assigned 1:1 CNA) stated that Resident #2 was observed laying in his bed, when Resident #1 returned from LOA. She was sitting outside the room, with the door cracked and could only visualize the upper part of Resident #2 ' s body. The room was quiet until screaming was heard coming from Resident #2 who yelled out, Leave me alone! Leave me alone! She pushed the door open and saw Resident #1 standing over Resident #2 (who was in bed) holding a knife with a black handle. She called for help, when the other staff came, Resident #2 pushed Resident #1 out the room, into the hallway, and closed the door. Resident #1 opened the door and spat on Resident #2. Resident #2 then came out of the room with a meal tray, hitting Resident #1 over the head three times. A male CNA (Employee #5) came and separated the two residents. She helped escort Resident #1 to the nurse ' s station. Employee #5 stayed with Resident #2 until the police arrived. During a face-to-face interview on 06/13/24 at 11:49 AM, Employee #7 (Unit 2 South's Unit Manager) stated that Employee #3 (DON) spoke with her on 06/06/24 about Resident #1 and Resident #2 not being compatible roommates due to both of their history of physically aggressive behaviors. She also had the same concern, that she brought to the DON's attention during the daily afternoon clinical administration meeting (stand-down) on 06/06/24 and during the daily administrative morning meeting (stand-up) on 06/07/24. However, she was informed by the DON that room [ROOM NUMBER] bed A was the only bed available in the facility to admit Resident #2. During a face-to-face interview on 06/13/24 at 5:17 PM, Employee #3 (Director of Nursing/DON) stated that Resident #1 has behavior problems, indecent exposure issues, and can be violent with staff and residents. Resident #1 has attacked him before with his power. He said that Resident #2 resided was on unit 3 south. The resident was territorial and didn't want anyone coming into his space. He had a roommate initially, but we never put anyone else in the room with him after the last roommate was discharged . Resident #2 had not had a roommate since I came back to work in June 2023. Facility staff couldn't even get into the room to get it ready for another admission. - Resident #2 did have a physical altercation with another resident which led to Resident #2 being FD12 by the facility ' s psychiatric team on 03/05/24. He was admitted to a local psychiatric hospital from 03/06/24 until 06/06/24 (90 days). According to Employee #3, the facility was unaware that the resident was returning to the facility on [DATE]. Resident #2 showed up to the facility lobby, getting out of a taxi. Earlier that same day, however, he, the Administrator, Department of Behavioral Health, the Ombudsman, and a representative from a local psychiatric hospital had a telephone conversation discussing Resident #2's return to the facility. The Psychiatric hospital personnel said the resident was stable to return. Employee #3 admitted that he questioned the resident's return after 90 days since the local psychiatric hospital didn't discuss the resident's medical management or provide any clinical background during his 90-day treatment course while at the psychiatric hospital. Employee #2 further stated that he received information about available beds from the Admissions Department. He was informed by the Admissions Department that room [ROOM NUMBER] bed A was available. The employee also stated that he did not think room [ROOM NUMBER] bed A was suitable for Resident #2 because of Resident #1's (room [ROOM NUMBER] bed B) unpredictable behaviors. However, he said he was temporarily placing Resident #2 in that room until he was able to find another room. Additionally, he informed the Administrator of his concerns. A review of the facility's resident census report dated 06/05/24 and 06/06/24 showed that room [ROOM NUMBER] bed B was available at the time of Resident #2's admission. However, Employee #3 stated that the Admissions Department did not make him aware that room [ROOM NUMBER] bed B was available, and that room would have been a better fit for Resident #1. Based on these findings, June 18, 2024, at 10:31 AM an Immediate Jeopardy (IJ) situation was identified. On June 18, 2024, at 5:45 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: The Administrator or designee immediately ensured the safety and well-being of the resident(s) by the following: - Resident (1) was taken into police custody on 6/8/2024; still in police custody - Resident (2) was sent to ER for medical evaluation for bleeding from the left leg on 6/8/2024. Resident (2) returned to room [ROOM NUMBER]A around 10:45 p.m. on 6/8/2024 with sutures to the left leg. - Resident (2) was placed on hourly monitoring upon return from ER; to be re evaluated on 6/18/2024. Resident (2) will remain in 220 without a roommate and re evaluated every 90 days. - Resident (2) was offered emotional and psych support by social services and Arising Psych Services on 6/10/2024. Resident declined both services. Care plan for refusals of care was revised on 6/14/2024 to include the resident's refusal of those services. Pysch services will continue monthly and as needed. - The Administrator/designee reviewed and revised the current process for bed assignments for new admissions, readmissions and room relocations in order to protect residents from potential abuse on 6/18/2024. The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 6/19/24) - Administrator, Assistant Administrator, DON, ADON, Unit Managers, Nursing Supervisors, Social Services and Guest Services will be educated by Regional Clinical Consultant/Designee on resident compatibility/agreement, to include documented aggressive behaviors, to ensure that room placements are appropriate and residents are protected from physical, psychosocial harm as well as additional abuse. New Admissions personnel will be educated on resident compatibility/agreement during orientation. - The Administrator/designee will conduct a review of current residents to determine if there are any documented complaints or grievances within the last 30 days related to roommate combability/agreement. Alternative options within residents rights, as related to F559, will be offered. - New, readmissions and current residents will be reviewed by Unit Manager's/Designee for compatibility/agreement, with considerations from F559, daily x5 then weekly x 4 then monthly x 4 or until compliance is sustained. - The Regional Director of Operations will visit the facility 6/19/2024 to provide oversight and additional training to Administration and Nursing Leadership based on compatibility/agreement audit findings. Corrective action completion date: 6/19/24 2. Facility staff failed to ensure Resident #4 was free from physical abuse by Employee #9. Resident #4 was admitted to the facility on [DATE] with multiple diagnoses including Left Side Hemiplegia and Hemiparesis following Cerebral Infarction, Muscle Weakness, Major Depressive Disorder, Restlessness and Agitation, Brief Psychotic Disorder, and Schizoaffective Disorder. A care plan revised on 03/14/24 documented in part, Focus- [Resident #4] was allegedly throwing stuff at another resident on 03/13/24 during a verbal interaction with another resident. Goal- [Resident #4] will have no episode of physical interaction towards another resident through the next review date x 90 days. Interventions- [Resident #4] was educated to report problems to staff instead of taking [matters] into his own hands. He verbalized understanding. Psych[iatric] consult to evaluate aggressive behavior. Referred to group therapy for coping skills . A care plan revised on 04/02/24 documented in part, Focus- [Resident #4] has a behavior problem r/t (related to) cursing, yelling and using profane language on staff and residents, physically abusive to staff .Interventions: Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings towards the situation. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Psychiatric/Psychogeriatric consult as indicated. When [Resident #4] 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 Quarterly Minimum Data Set (MDS) dated [DATE] documented in part, the resident had a Brief Interview for Mental Status summary score of 06 indicating the resident was had severely impaired cognitive status. The resident was also coded for: verbal behavioral symptoms directed towards others (threatening others, screaming at others, and curing at others), rejection of care, and taking antipsychotic medications. A nursing supervisor nursing note dated 06/15/24 at 1PM documented, Late Entry: Note Text: The resident, [Resident #4] reported that his assigned CNA [Employee #4] had brought him a cup of Lemonade juice and try to take the other cup of juice that was on his table. [Resident #4] said leave it alone I just got that juice the staff said she left the cup of juice and on her attempting to leave the room, [Resident #4] picked one of the cup of juice and threw it at her. The CNA turned around as [Resident #4] was attempting to throw the second cup of juice, and she grabbed the cup of juice from him and threw it on him. DC Metropolitan police was called and [officer's name and badge #] and [officer's name and badge] came to the facility at 12:35pm. Spoke to the staff . The police then said we should follow through with the facility policy. [Primary Medical Doctor/PMD] notified. Resident refused assessment and vital signs from writer nor his nurse. Resident's guardian [guardian's name] made aware. Will continue to encourage and redirect resident to report any concerns to the supervisor or his nurse. A FRI, DC~12888, received by the State Agency on 06/17/24 at 9:01 AM documented in part, [Resident #4] .reported that [Employe #8, CNA] hit me on my forehead and scratched me in the process. She had on rings on her hands. She threw a cup of ice with juice on me. The investigation is still in progress . An observation on 06/17/24 at approximately 11:20 AM revealed Resident #4 sitting in his room in his motorized wheelchair. He was alert, dressed, wearing glasses, and was able to understand his name, the time, the place, and the situation. He had left side hemiplegia and a left above-the-knee amputation. Additionally, the resident had three small scratches and redness on his forehead. At the time of the observation, he stated that Employee #9 (assigned CNA) hit him in the face and his glasses came off during their altercation on 06/15/24. He also claimed that the employee was wearing rings at the time, and they may have scratched his skin during the altercation. In the resident's account, the altercation began when Employee #4 was passing water and ice outside his room door. When he asked her to move, she cursed out and became upset. In addition, she threw lemonade and juice at him. However, he denied hitting Employee #9 or throwing lemonade at her. During a face-to-face interview on 06/17/24 at 5:10 PM, Employee #10 (assigned LPN) reported seeing Employee #9 (assigned CNA) at the resident's door. She heard Employee #9 say stop throwing ice on me. On the floor of the resident's room, she observed ice and water. Further, she noticed scratches on the resident's forehead that weren't there at the start of her shift. He refused to talk to her or allow her to assess him. During a face-to-face interview on 06/18/24 at 8:15 AM, Employee #11 (RN/Supervisor) stated that Employee #9 (assigned CNA) admitted to throwing water and lemonade at Resident #4 after the resident attempted to throw a second cup of lemonade and ice at her. When he observed the resident, he noticed the resident had scratches on his forehead and his shirt was wet. Additionally, the resident was upset and cursing. The resident was also unwilling to talk or be assessed. Following the incident, the resident left the floor and was unavailable to speak with police. During a telephone interview on 06/18/24 at 1:13 PM, Employee #9 (assigned CNA involved in the incident) stated that Resident #4 became upset when she tried to give him a second cup of lemonade with ice. She placed the lemonade on his table in front of him and said I just came to give you a cup of juice. When she was leaving the room, the resident threw a cup of lemonade at her. As she turned around, she noticed that he was attempting to throw a second cup of juice, so she grabbed a cup of lemonade off her cart and threw it at the resident. She believes it may have hit the resident in the face. However, as far as she could recall, neither she nor the resident hit one another, and she did not notice scratches on the resident's forehead. Additionally, she said she had attended many in-services related to managing residents with challenging behaviors, and she had learned to leave the room when an altercation or incident occurred and report it to a nurse or supervisor. Cross Reference 22B DCMR Sec. 3269.1l 41645

Based on observations, record reviews, resident and staff interviews, for five (5) of 16 sampled residents, the facility's staff failed to: (1) implement safety measures to prevent Resident #1 from having access to a lighter. As a result, Resident #1 lit Resident #2's bedsheets and mattress on fire with the lighter at approximately 11:25 PM on 04/20/24. (2) Ensure Resident #8's safety by providing adequate supervision to prevent her from wandering into other residents' rooms, resulting in Resident #8 sustaining a head laceration when Resident #6 hit her in the head with a cane for wandering into his room on 02/08/24. (3) Ensure Resident #6 was adequately supervised while possessing a cane following an incident where he used it as a weapon on 02/08/24. Subsequently, forty-six days later (03/26/24), Resident #6 used the cane again to strike Resident #7 during an incident, and in the process Resident #6 fell and suffered a severe head injury. Additionally, Resident #7 was struck in the shoulder with the cane. These failures resulted in an immediate jeopardy situation. The immediate jeopardy was identified on April 25, 2024, at 12:41 PM. The facility provided a plan of action to address the immediacy on April 25, 2024, at 10:41 PM and it was accepted. After the plan was verified the IJ was removed on May 2, 2024, at 5:08 PM while the survey team was onsite. After the removal of immediacy, the deficient practice remained for the potential for minimal harm, with the scope and severity of G. These failures also resulted in actual harm to Resident #8 on 02/08/24 and Residents' #6 and #7 on 03/26/24. The findings included: 1. Resident #1 was admitted to the facility on [DATE]. The resident had multiple active diagnoses that included Schizophrenia, Bipolar Disorder, and Psychosis. A review of the Resident Smoking contract signed by Resident #1 and verbally acknowledged by the resident's responsible party on 02/02/23 documented in part, smoking material of residents requiring supervision with smoking should be maintained by staff. It should be noted the resident was not given a new contract after the smoking policy was revised on 08/30/23. A review of the Smoking policy dated 8/30/23, revealed the following policy statement: It is the policy of the facility to provide reasonable accommodations to residents who smoke, while maintaining a safe environment for all residents, visitors, and staff. Residents are not permitted to possess their own cigarettes or other smoking material. All smoking materials will be kept secure by the facility. If at any time it becomes known by facility staff that a resident is in possession of smoking materials and/or has smoked in an unauthorized area, the resident will be asked to turn such material over to the facility staff. It should be noted that when the policy was updated the resident did not sign a new smoking contract. Resident #1's medical record failed to reveal a subsequent smoking contract after the revision of the facility's smoking policy on 8/30/23. A physician's order dated 09/19/23 instructed, Resident to voluntarily submit to search for smoking paraphernalia on resident and in resident's room each shift and upon return from any outing/LOA (Leave of Absence) from the facility. Remove smoking paraphernalia if found. Every shift for safe smoking policy enforcement. A care plan with a revision date of 10/14/23 documented, Focus- Resident #1 is a dependent smoker and will not be able to carry either tobacco or incendiary devices at any time. Resident #1 was caught with a cigarette in her mouth and would not give it up. She is supplied with cigarettes three times a week. Goal- Resident #1 will practice safe smoking while in the facility by abiding [by] facility smoking policies through next review period. Intervention- Resident #1 will allow searches every shift on herself and her room for smoking paraphernalia and removal of such paraphernalia when found. Searches will be signed off by the nursing staff on the Treatment Administration Record. A review of the resident's Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status summary score of 11 indicating that the resident had moderate cognitive impairment. The resident was also coded for verbal behaviors (threatening others, screaming at others, cursing at others) toward others, other behavioral symptoms not directed towards others (physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and using anti-psychotic medications. A review of Resident #1's 03/19/24 Smoking Evaluation documented in part, Resident is safe to smoke with supervision and protective smoking equipment. Resident is safe to light own cigarette with staff supervision. A review of the April 2024 Treatment Administration Record (TAR) revealed the following physician order, Resident to voluntarily submit to a search for smoking paraphernalia on resident and in resident's room each shift and upon return from any outing/LOA from the facility. Remove smoking paraphernalia if found. every shift for safe smoking policy enforcement. The TAR showed that staff signed their initials from 04/01/24 to 04/19/24 for day shift (7AM - 3 PM), evening shift (3 PM to 11 PM), and night shift (11 PM - 7AM) indicating that they searched the resident and her room for smoking paraphernalia. Additionally, on 04/20/24 the licensed practical nurse (LPN; Employee #6) signed her initials for dayshift and evening shift indicating that she searched the resident and the resident's room for smoking materials. A review of a 04/20/24 Cigarette Count Sheet for 3PM to 11PM documented that the resident was provided one cigarette by staff between 3:00 PM and 8:30 PM. A nursing progress note for Resident #1 dated 04/21/24 at 3:43 AM documented in part, Note Text: Allege fire: Around 11:25pm writer heard a call for help for [room#] and on entering the room, writer notice that left side of B-bed is on fire. When asked what happen resident said, The boy and the girl have been together for a long time and the girl does not want to be with him anymore and he want to kill her Writer direct resident to area of safety and fire was immediately extinguish. Resident refuse skin assessment and also refuse writer from searching her or her bag for any inflammable object like lighter. resident's room was search and no lighter found. 911 was call .7th district came to the unit around 11:45pm, report was taken and [report #] was assigned to the incident and the police called DC fire investigator and officer . came to the unit [and] report was taken. NP [nurse practitioner] made aware and order to transfer resident for emergency psychological evaluation via 911 due to setting the roommate's bed on fire. DC fire Marsal left with resident in a stretcher to [hospital's name] around 1:23am. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses including Major Depression, Schizophrenia, Dementia, and Difficulty Walking. A review of an Annual Minimum Data Set, dated [DATE] documented in part the resident had a Brief Interview for Mental Status summary score of 11 indicating that the resident's cognitive status was moderately impaired. Also, the resident was coded for tobacco use. A nursing note for Resident #2 dated 04/21/24 at 4:13 AM documented in part: Note Text: Bed On Fire: Around 11:25pm writer heard a call for help for [room #] and on entering the room writer notice that left side of B-bed is on fire. When asked what happen resident [Resident #2] said I was sitting in bed when my roommate [Resident #1] light my bed on fire and I quickly get in the chair and leave the room Writer direct resident to area of safety and fire was immediately extinguish. Upon assessment no burn injury noted, no bleeding or redness noted. resident denies pain. [Resident #2] agree to voluntary search and no inflammable object like lighter found. 911 was call and [two officers names and badge numbers] of 7th district came to the unit around 11:45pm, report was taken and [report#] was assigned to the incident and the police called DC fire investigator and [officer's name] came to the unit report was taken no arrest or charges file . BP(blood pressure) 121/69, T (temperature) 97.7, P (pulse) 83, R (respiration) 20, SPO2 (oxygen saturation) 99%RA (room air). A State Agency Facility Reported Incident DC~12656 dated 04/22/24 at 6:29 PM documented, It was reported by a resident [Resident #2] that the side of her mattress had a fire staff immediately went to the room and extinguished it by throwing a cup of water over it. No residents were negatively affected. Metropolitan Police Department and the District of Columbia Fire department did arrive post incident, and no interventions were needed. Resident was provided a mattress. During an end of day survey meeting on Monday 04/22/24 at approximately 4:30 PM, with Employee #1 (Administrator) and Employee #2 (Director of Nursing; DON), Employee #1 asked if they should report an incident related to Resident #1 allegedly setting Resident #2's mattress on fire on Sunday [04/21/24] The Administrator stated there were no flames and the mattress was just melting a little bit. The Administrator also stated that a nurse put the fire out with a cup of water. He then said no residents were harmed, and Resident #1 was sent to the hospital for psychiatric evaluation. The surveyor asked to see the mattress and was told the mattress had been thrown away and was not available for observation. An observation of Residents #1's and #2's on 04/23/24 at approximately 10:00 AM revealed no smell of smoke or evidence of a burned mattress. Additionally, Resident #2 was observed lying awake in Bed B. According to the resident, she was lying in bed when her roommate (Resident #1) set fire to her mattress with a red lighter. Then, she stated that she was in her wheelchair when her mattress was set on fire. She admitted that she hadn't fought or argued with Resident #1 before the incident. Furthermore, she denied any injuries, saying, I am fine, and I don't want to move. During a face-to-face interview on 04/23/24 at approximately 10:15 AM, Resident #3 who resided in the room to the left of Resident #1 and #2's 's room, stated that around 11:00 PM on Saturday 4/20/24 he heard Resident #1 and Resident #2 arguing and bumping up against the wall. As he was going to their room, he saw Resident #2 rolling in her w/c towards the nursing station. He reported that when he got to Resident #1 and #2's room, he saw Resident #1 leaning over from her bed and she lit Resident #2's bed on fire. The resident also said that when he saw flames he yelled HELP, and no one came. So, he then yelled FIRE, FIRE and the nurses came running and said yes, we can smell it. According to him, a nurse put out the flames with a cup of water. During a face-to-face interview on 04/23/24 at 2:45 PM, Employee #6 (LPN) stated that she was the assigned nurse for Residents #1 and #2 on 04/20/24 between 7AM and 11PM. Following her report to the on-coming night shift nurse, she saw Employee #4 (RN) and Employee #5 (RN) heading for [Residents #1 and 2's room] and heard FIRE, FIRE, so she ran there too. The employee stated that when she got to the room, she didn't see fire, but she smelled heavy smoke. According to the employee, although she signed the Treatment Administration Record indicating that she physically searched Resident #1 and her room for smoking materials on 4/20/24, she does not routinely physically search residents for smoking materials. She indicated that she will ask for consent to search if she suspects that they may have smoking material. Additionally, she reported that Resident #1 will not allow anyone to physically search her because she will scratch and bite you. However, the employee stated that she did search Resident #1's room and found no smoking materials. It should be noted that Employee #6 signed her initials on the April 2024 TAR seven times between 04/06/24 and 04/18/24 indicating that she physically searched Resident #1 and her room for smoking materials. During a telephone interview on 04/23/24 at 3:42 PM, Employee #4 RN (assigned night nurse) stated that she was at the nurse's station when Resident #3 call for help. He was pointing to [Residents #1 and #2's room] When she and Employee #5 (RN) went in the room bed B was on fire with flames. I got a cup of water from the sink. I pour it on the fire and it went off. While she was putting the fire out, another employee moved the residents who were sitting at the doorway to safety. The employee said Resident #1 could not explain what happened, and Resident #2 said, she was sitting on the bed when Resident #1 light the bed up, so she had to get out the room. The employee said that the left side of the mattress was on fire. Resident #1 refused to be searched. Resident #2 was searched and no lighter or matches were found. The nursing staff also searched the room after Resident #1 was sent to the hospital. They did not find a lighter, matches, or cigarettes. When asked about the order on the TAR to search the resident and the resident's room for smoking material, the employee said that she searches the resident's room for smoking material when she leaves, and she searches the resident's bag when the resident is sleep . The employee said during her searches she has never found any smoking material. Furthermore, the employee said that Resident #1 would not allow her to physically search her, but she has never documented that the resident refused to be searched. It should be noted that Employee #4 signed her initials on the April 2024 TAR ten times between 04/06/24 and 04/18/24 indicating that she searched physically Resident #1 and her room for smoking materials. During a face-to-face interview on 04/23/24 at 4:34 PM, Employee #8 (Unit Manager/RN) stated that staff do not physically search Resident #1 for smoking material. Staff will ask the resident if she was smoking if they observe smoking material. If she gives permission, they will search the resident's room in her presence. Employee #8 also reported staff should document the resident's refusal to have her room searched. Please note, a review of progress notes from 04/01/24 to 04/23/24 lacked documented evidence that Resident #1 refused to be searched or have her room searched for smoking materials. Based on these findings, on April 25, 2024, at 12:41 PM, an Immediate Jeopardy (IJ) situation was identified. On April 25, 2024, at 10:41 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: o Rl [Resident #1] was transferred to hospital for evaluation on 4/20/2024 under FD-12. On 4/24/2024 DBH was contacted in efforts to facilitate a collaborative effort in identifying an appropriate plan of care for the resident. On 4/25 there was a meeting with Chaka Curtis and hospital social workers to further discuss appropriate placement of Rl based on her mental health needs. When resident does return, resident will be placed on hourly visual check. The Department of Behavioral Health nursing home Liaison, Chaka Curtis, will follow and assist with identifying resources for managing Rl 'scare. o R2's [Resident #2] damaged mattress was replaced on 4/21. Social Work followed up on 4/23/2024 for emotional support post incident. R2 was alert + oriented 3x, and acknowledged she was recovering well despite recent trauma. SW validated her feelings and encouraged her to share any concerns she has with her clinical team and social work staff. Resident was encouraged to participate in psychotherapy in regard to processing her thoughts and feelings. SW completed a psych referral on referral on 4/23/2024 and will be followed up on 4/26/2024. o The facility has determined that all residents have the potential to be affected. Of those 283 residents, 83 residents were identified as smokers through the review of all resident smoking assessments. 83 of 83 identified smokers are considered safe to smoke with supervision and protective smoking equipment. All cigarettes are lit by staff. o The facility smoking policy was reviewed and revised by 4/25/24. Number 5 was edited. See attached. o In-services will be initiated for facility staff on the revised smoking policy upon review by the Quality Assurance Committee on 4/25/24 and completed by 4/29/2024. Education will be ongoing until all staff have been educated. Staff will not be allowed to work until education is completed. o CNA's will supervise smoking times (8:30am- 11 :OOam and 1:30pm- 4pm. and 6:00p.m.- 8:00 p.m.) to ensure there is adequate supervision and ensure that all smoking materials not used are returned to the secure area to help prevent smoking related incidents. o During unit rounds, every 2 hours, facility clinical staff (Nurses and CNAs), will visually observe that residents do not have possession of smoking paraphernalia to help ensure safety of residents. Any violations will be reported to the Administration/Designee including supervisors immediately. o If there is suspicion of unusual occurrences related to smoking concerns or violation of the smoking policy/contract the facility will request permission to search room/personal property. If a resident refuses, a violation form will be issued. Smoking contracts will be reviewed with residents and representatives for re-education on this policy by 04/26/2024. o An ad-hoc meeting will be held with residents on 4/26/2024 addressing the revised policy. The facility assigned ombudsman will attend the resident council meeting scheduled for 5/02/2024 to provide support in explaining the importance of adhering to the facility smoking policy. o Starting 4/26/2024, as a safety precaution, a smoking log will be implemented and maintained by the DON/designee to document and track unwarranted movement of smoking paraphernalia by residents. Staff are to notify DON/designee of occurrences. o Starting 4/26/2024 the NHA/designee will complete a smoking log during visual observational rounds at designated smoking times to ensure adherence to facility policy. o Starting 4/26/2024 the Director of Nursing/designee will complete a smoking log during random visual observations of residents who smoke to ensure that residents do not possess observable smoking paraphernalia throughout the facility. o If any resident is noted in violation of the facility smoking policy next steps may include: o Information and education on smoking cessation in collaboration with the physician and/or alternative placement from the facility if behaviors present a danger to self or others. Corrective action completion date: 4/29/2024 Verification of the removal of the immediacy was performed by the survey team onsite on May 2, 2024, at 5:02 PM. Cross reference 483.12 Freedom from Abuse, Neglect, and Exploitation (F607 and F609); and 22B District of Columbia Municipal Regulations (DCMR) - Nursing Personnel and Required Staffing Levels (sect. 3211.1d). 2. Resident #6 was admitted to the facility on [DATE]. The resident had a history of Schizoaffective Disorder, Bipolar Disorder, Major Depressive Disorder, Unspecified Psychosis Disorder, Generalized Anxiety, Unspecified Intracranial Injury with Loss of Consciousness, and Disorder of Brain. A physician order dated 11/16/22 instructed, Monitor for specific behaviors: verbal [abuse], physical abuse, refusal of care. A care plan with a start date of 12/07/23 documented in part the following: Focus - [Resident #6] pushed another resident to the wall causing that resident to fall to the floor on 12/06/23 at 1:50 PM due to poor impulse control. Goal-[Resident #6] will have no episodes of physical aggression to staff and residents .Interventions-Analyze key times, places, circumstances, triggers, and what de-escalate behavior and document. Assess and anticipate resident's needs, food, thirst, toileting needs, comfort level, body positioning, pain etc. Assess resident's coping skills and support system. Assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation, Evaluate for side effects of medications. Monitor and document observed behavior and attempted interventions in behavior log. Psych (psychiatric)/Psychogeriatric consult as indicated. DOH, Police depart. (department) and OMB notified. Schedule a Behavior Care Plan meeting to discuss other methods/strategies to better address [Resident #6's] needs. An Annual Minimum Data Set, dated [DATE] revealed the resident had a Brief Interview for Mental Status summary score of 13 indicating the resident was cognitively intact. And the resident was coded for: no impairments with upper and lower extremities, being independent with walking in room, set-up or clean up assistance with ambulation, and his resident's personal belongings and having a place to store them as being very important to him. 2a. Resident #8 was admitted to the facility on [DATE] with multiple diagnoses including Anoxic Brain Damage, Vascular Dementia, Psychotic Disorder with Delusions due to known Psychological Conditions. A review of a physician orders revealed an order to discontinue, 1:1 staff monitoring for safety every shift on 01/10/24. It should be noted that this order started on 07/19/23. A Quarterly Minimum Data Set assessment dated [DATE] revealed the resident's Brief Interview for Mental Status summary score was 03, indicating severe cognitive impairment. And the resident was coded for verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others), rejection of care, and wandering. A review of a physician order dated 01/11/24 instructed, Hourly monitoring for resident for seizure. The nursing progress note dated 01/14/24 at 8:08 AM documented, Resident has been wandering from the hallway to other residents' room there by agitating them which in most cases leads to heated arguments and intervention from the staffs. So far she has always been redirected and guided to her room but it's not effective since she does not have any aide staying with her and directing her as to where to go but most importantly guide her from dangers of been beating by resident she freely walks into their room. A review of nursing progress notes revealed that on four separate occasions from 01/15/24 to 01/19/24, staff had to re-direct Resident #8 after she wandered into other residents' rooms. A review of Resident #8's care plans with a revision date of 01/22/24 documented the following but not limited to Focus- [Resident #8] has Seizure disorder. Goal-[Resident #8] will be/remain free of seizure activity through review date. Intervention- Give seizure medication as ordered by doctor. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. It should be noted that although the care plan was revised on 01/22/24 it lacked documented that the intervention for Hourly monitoring for resident for seizure., as ordered on 01/11/24. Focus- [Resident #8]-has an elopement risk/wanderer AEB (as evidenced by) impaired safety awareness. Interventions included a psychiatric consult with [provider's name] services and staff will continue to redirect [Resident #8] back to his [her] room . There was no documented evidence of a care plan with approaches and goals to address the resident's hourly monitoring order dated 01/11/24. Further record review revealed Resident #8 wandered into other residents' rooms eight (8) more times between from 01/22/24 to 02/06/24. Review of Resident #6's medical record revealed a nursing supervisor note dated 02/08/24 at 9:19 PM documented Physical Aggression Initiated: At about 4pm it was reported that the resident stated that he hit one female. Resident was asked if he hit someone? Resident said, Yes I hit her because she comes to my room to steal my stuff. She thinks I am playing with her and I am not. I hit her with my cane so that she would not come again to my room. Resident was educated on not to hit other residents. Resident said, I will not do it except if someone comes to my room and touch my belongings, I stay at this corner, I don't bother anyone'. [Officer's name and badge #] told the resident that he can be arrested for hitting other residents. Resident said, Okay arrest me now do you think I care. [Officer's name] gave [report #]. No arrest was made. [Officer's name] is waiting for warranty (sp) of arrest for simple assault. [Doctor of Nursing Practice name] notified gave order for Psych (psychiatric) consult and to monitor resident q (every) hourly (sp) x 72 hrs (hours). R/R [responsible party/guardian/family member] name left a message when incident happened, however she called back at 8:41pm and was notified the incident happened. [Emergency Contact #1's name] notified. OMB [Ombudsman] left a message. Will continue with current plan of care. A nursing progress note dated 02/08/24 at 10:11 PM for Resident #8 documented, Physical Aggression Received: At about 3:40pm staff reported that resident was observed walking towards the nursing station from another floor bleeding from her head. Resident is unable to state what happened. Resident is alert and oriented x 1. On assessment resident is noted with a laceration on the head with small amount of blood. No signs of pain noted. Resident stated she is ok when asked if she was in pain. V/S BP 131/94 P69, T98.6, R18. Pressure was immediately applied by staff to stop the bleeding and [MD] made aware with new order to transfer resident to the nearest ER for further evaluation. 911 and Police officers were called. EMS responded at 4:15pm and police officer spoke to both residents . [Resident #8] was transported to [hospital's name] at about 4:57pm. Resident's [responsible party] daughter was present at the time of the incident and is aware. A review of Resident #8's nursing progress note dated 02/09/24 at 3:50 AM documented in part Resident returned back from [hospital's name] ER at 2 am .Left side of the head has 5 staples with no active bleeding noted . Left parietal scalp laceration without evidence of acute displaced fracture . CT spine cervical w/o (without) contrast. Impression: No CT evidence of acute displaced fracture involving the cervical spine . Resident #8's physician order dated 02/09/24 instructed, 1:1 observation for seizures AMS (Altered Mental Status). An additional nursing progress note for Resident #8 dated 02/14/24 at 11:08 AM documented, Note Text: IDT (Interdisciplinary Team) met and discussed allerged [alleged] aggrassion [aggression] resident received from another [Resident #6] which resulted in resident sustaining a cut on the left upper scalp area .a 1:1 staff has been assigned to resident upon resident's return from the hospital . A State Agency Facility Report Final Intake form (DC~12693) dated 02/13/24 documented in part, On February 8, 2024, at approximately 4:00 PM, and alleged resident to resident physical altercation was reported. It was communicated that [Resident #6] allegedly struck [Resident #8] on the head with his cane . [Resident #8] had a laceration on the left side of her head with small bleeding .[Resident #8]was transferred to the emergency room for further treatment and evaluation .After a full investigation, the facility substantiates .[Resident #6] struck [Resident #8] in the head with a cane . During a face-to-face interview on 04/30/24 at 3:43 PM, Employee #9 (Nursing Supervisor) stated that when Resident #8 came from Unit 3 North, staff observed blood on the back of her head near her ear. According to the employee, staff informed her that [Resident #6] reported hitting someone. He said that he didn't want to see her [Resident #8] on his side [3North]. When asked if Resident #6 used a cane for ambulation, she stated that she was not sure because she works with the residents on the south side of the building and Resident #6 was on the north (3 North) side of the building. During a face-to-face interview on 04/30/24 at 4:15 PM, Employee #10 (Registered Nurse; RN) stated that [Resident #6] was assigned to her during the evening shift on 02/08/24. She said [Resident #6] told her that he hit someone, but he didn't say who or how. She was informed later that evening that [Resident #8's] head was bleeding after she left Unit 3 North. This is when she informed her supervisor that Resident #6 had hit someone. The employee also stated that she did not observe Resident #8 on Unit 3 North, nor did she hear any arguments. Furthermore, the employee said that she has worked with Resident #6 for a few years and has never seen him use a cane to walk. During a face-to-face interview on 04/30/24 at 4:36 PM, Employee #11 (Nursing Supervisor) stated that when she was called to Unit 3 South, she noticed Resident #8's head was bleeding, so she applied a pressure bandage. The staff informed her that the resident had bleeding on her head when she returned from Unit 3 North. She called 3 North and spoke with Employee #10 (RN), who informed her that Resident #6 told her that he hit someone, but he could not tell her who it was. According to the employee, Resident #8 was sent to the ER (emergency room) for evaluation and the police were called. After the police arrived, she and the police spoke with Resident #6. The resident was angry and said he hit Resident #8 with a cane because she came to steal his things. The resident demonstrated what happened to the police. In his demonstration, Resident #8 was standing at the sink when Resident #6 struck her on the left side of the head with a cane. He refused to give the cane to the police when they asked for it. In addition, the employee reported that she has never seen Resident #6 use a cane to walk. A nursing note dated 02/08/24 at 9:19 PM for Resident #6 documented, Physical Aggresssion Initated: At about 4pm it was reported that the resident stated that he hit one female. Resident was asked if he hit someone? Resident said, Yes I hit her because she comes to my room to steal my stuff. She thinks I am playing with her and I am not. I hit her with my cane so that she would not come again to my room. Resident was educated on not to hit other residents. Resident said, I will not do it except if someone comes to my room and touch my belongings, I stay at this corner ,I don't bother anyone' .[Officer's name] told the resident that he can be arrested for hitting other residents. Resident said ,Okay arrest me now do you think I care . No arrest was made . [DNP's name]notified gave order for Psych consult and to monitor resident q hourly x 72 hrs . A care plan dated 02/08/24 documented, Focus- [Resident # 6] had a physical aggression towards another resident 2/8/24. Goal- [Resident #6] will have fewer episodes of aggression towards another resident through the next review date x 90 days. Interventions- Hourly monitor x 72 hours. MD/NP notified. Police [report #] given with no arrest was made. DOH (Department of Health) online portal reporting done. OMB (Ombudsman) notified via voicemail. Psych consult to evaluate aggressive behavior towards another resident. Continued review of the resident's care plan lacked documented evidence of a care plan to address goals and approaches to address the resident to safely use of a cane (used to aid with minor balance and steadiness issues) for its intended purpose. A document for Resident[TRUNCATED]

Based on record review and staff interviews, for two (2) of 12 sampled residents, facility staff failed to implement corrective actions to prevent further potential abuse or mistreatment of Resident #12 while the investigation is in progress and failed to conduct a thorough investigation of Resident #2's allegation of employee abuse. Residents' #12 and #2. The findings included: Review of the facility policy Abuse, Neglect and Exploitation last reviewed on 05/19/23 documented, .Investigations of alleged abuse .include . identifying and interviewing all involved persons, including . others who might have knowledge of the allegations .The facility will make all efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include . room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator . 1. Facility staff failed to implement corrective actions to prevent further potential abuse or mistreatment of Resident #12 while the investigation is in progress for an allegation of physical abuse. Resident #12 was admitted to the facility on [DATE] with multiple diagnoses that included: Schizophrenia and Bipolar Disorder. Review of Resident #12's medical record revealed the following: A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: a Brief Interview for Mental Status (BIMS) score of 08, indicating mildly impaired cognitive status; no indicators of psychosis or behaviors towards others; no functional impairment in range of motion; and received antipsychotic medications on a regular basis. A Nurse's Note dated 07/06/23 at 8:35 AM: Assume care of resident, resident can be heard screaming in hall for nurse. Entered room. Resident guarding left wrist, visibly upset, states she is in pain. Per resident her wrist was twisted by a GNA (Graduate Nurse Aide) during the night shift, She reported incident to a [NAME] Male nurse She ask for the police to be called and she wanted to go to the hospital. Resident states nothing was done. Resident stating she herself has just called 911 and is requesting immediate actions be taken. Resident assessed for injury, sustained Unit Manager notified. A Situation Background Assessment Request (SBR) Communication Tool dated 07/06/23 at 8:45 AM: Situation, [Resident #12] reported allegation _ female CNA (Certified Nurse Aide) twisted her wrist and hit it on the side rails and hit her face .c/p (complained of) pain on her left wrist/ slightly swollen .left hand/ wrist was slightly swollen with slight discoloration complaint of pain in scale of 7/10 .Provider visit ( . Identify who and when): [Nurse Practitioner's name] . X- ray of the hand /wrist . Physician's orders dated 07/06/23 directed, Xray left wrist/hand STAT for Left Wrist Pain/Swelling and orthopedic consult to evaluate left wrist/hand . A Facility Reported Incident (FRI), DC~12072, received by the State Agency on 07/06/23 documented, Resident alleged that a female CNA grabbed her left wrist this morning and hit it on the side rails/enabler twice and hit her on the left face . A Radiology Report dated 07/06/23: . Procedure, left hand, 2 views . findings: There is hand arthritis, periarticular demineralization . Hand arthritis. No evidence of fracture . A follow-up from the facility received from the State Agency on 07/11/23 documented, On July 06, 2023 . an alleged employee to resident physical altercation was reported. [Resident #12] communicated that CNA, [Employee #14] grabbed her left wrist and hit it against the bed enabler . the facility substantiates the alleged employee to resident physical altercation . [Employee #14] was suspended pending full investigation . An Incident Note dated 07/13/23 at 1:17 PM: IDT (interdisciplinary) Summary; Allegation of abuse dated 7/6/23. IDT team had a discussion today regarding the Allegation of Abuse dated 7/6/23 .it was concluded that the root cause is Allegation of abuse. Following intervention in place: Police was called in the building .Psych consult for evaluation was provided with Comfort and assurance for her safety . A Complaint, DC~12202, received by the State Agency on 08/16/23 documented, .I received a call . [Resident #12] sated to staff that an unknown nursing staff had injured her by twisting her arm . During a face-to-face interview conducted on 08/23/23 at 3:52 PM, Employee #14 (CNA/alleged perpetrator) stated, It was time to go provide care for her [Resident #12]. She said she wanted a male not a female. I went and got another female colleague and went in, the resident still refused. I reported it to [Employee #7/male Licensed Practical Nurse/LPN]. He took two other CNA's with him to provide her care, not me. The resident did not report any issues to them or me. We all went home and later on, I got a call about the allegation that was made. When I came to work later that day (07/07/23 for the evening shift ), [Employee #15/ Unit 3 South Manager] took me to [Resident #12's] room and asked the resident if it was me who twisted her wrist. She (Employee #15) asked [Resident #12] three times and each time the resident said no, it was not me. I worked my shift and then worked that Thursday (07/06/23), Friday (07/07/23), Saturday (07/08/23) and Sunday (07/09/23) on 3 south. When I came back on Monday, 07/10/23, I heard that the State was in the building and that's when I was told that they (Administration) needed to suspend me due to protocol. When I came back to work after the suspension, they had moved me to another floor. Review of the unit 3 south assignment sheets showed that Employee #14 worked on unit south from 07/06/23 to 07/09/23 (4 days) and on 07/09/23, night shift (11:00 PM to 7:00 AM), Employee #14 was assigned to Resident #12. The evidence showed that facility staff failed to prevent further potential abuse or mistreatment of Resident #12 while the investigation is in progress. A face-to-face conference was conducted on 08/23/23 at 4:13 PM with Employee #1 (Administrator), Employee #2 (Director of Nursing/DON), Employee #3 (Clinical Manager) and Employee #15. Employee #15 stated, The resident was not able to give a name of who twisted her arm but she gave a description. Under the direction of Employee #3, I was instructed to bring in all the staff and present them to [Resident #12] for identification. I brought [Employee #14] to the resident to make a positive identification but the resident stated three times that it was not [Employee #14] who twisted her arm. She couldn't identify any of the staff that was presented to her. When asked who made the decision to suspend Employee #14 and not anyone else, Employee #2 stated, The employee had a previous allegation made where a resident said their arm was twisted. [Employee #14] was suspended based on our investigation. Employee #1 stated that he was not aware that Employee #3 had instructed Employee #15 to bring staff to Resident #12 for identification. When asked why is Employee #14 is still allowed to work in the facility if their investigation substantiated the allegation of physical abuse, none of the employee's mentioned above provided a response. On 08/23/23 at 4:13 PM Employee #1 acknowledged the finding that facility staff failed to prevent further potential abuse or mistreatment of Resident #12 while their investigation was in progress and made to further comments. Cross Reference 22B DCMR - Sec. 3232.2 2. Facility staff failed to conduct a thorough investigation of Resident #2's allegation of employee abuse as evidenced by not having interviews/statements from all staff that might have knowledge of the incident. Resident #2 was admitted to the facility on [DATE] with multiple diagnoses that included: Type 2 Diabetes, Urinary Tract Infection, Muscle Weakness, and Paraplegia. Review of the resident's medical record showed the following: A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition; no potential indicators of psychosis and no rejection of care behaviors exhibited. A Facility Reported Incident (FRI), DC12155, received by the State Agency on 08/01/23 documented, On Tuesday August 1, 2023, at approximately 3:00 PM, an alleged employee to resident altercation was reported. It was communicated that [Resident #2] reported that sometime On May 28, 2023, [Alleged perpetrator/Registered Nurse] twisted his left wrist when removed medications from [Resident #2's] hand . Review of the facility's investigation documents on 08/21/23 showed that they failed to conduct a thorough investigation as evidenced by not interviewing all persons who might have knowledge of the allegation. There was no interview of the Certified Nurse Aide (CNA) who was assigned to Resident #2 on the date of the alleged incident (05/28/23). A conference was held on 08/21/23 at 4:03 PM with Employees #1 (Administrator), #2 (Director of Nursing/DON), #3 (Clinical Director) and #4 (Quality Nurse). When asked if they interviewed all staff with possible knowledge of the alleged incident, to include the staff assigned to Resident #2 on 05/28/23, Employee #1 stated, No.

Based on record reviews and staff interviews, facility staff failed to provide appropriate social services to meet resident's needs as evidenced by failing to advocate and assist one (1) of 17 sampled residents in the assertion of their rights within the facility, and to have immediate, direct supervision of Licensed Graduate Social Workers (LGSW) by a Licensed Independent Clinical Social Worker (LICSW). This failure had the potential to affect all residents of the facility. The census on the first day of the survey was 294. Due to these failures, an Immediate Jeopardy (IJ) was identified on November 15, 2023, at 5:27 PM. The facility's Administrator provided a corrective action plan to the Survey Team on November 15, 2023, at 8:46 PM, while the team was on site and the plan was accepted. Verification of the removal of the immediacy was performed by the survey team onsite on November 17, 2023, at 1:53 PM. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm for all remaining residents at the scope and severity of F. The findings included: Review of the facility's Social Services policy dated 07/26/23 documented: - The facility will provide medically related social services to each resident, to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. - Services to meet resident's needs may include: advocating for residents and assisting them in assertion of their rights within the facility; assisting residents in voicing and obtaining resolutions to grievances. Review of a Resident Interview/Assessment form dated 11/10/23 at 3:13 PM documented the following: - Resident #1's name - Has any resident touched you or tried to kiss you without your consent - Yes - If the response is yes to other question, please describe: [Resident #2] (dark skin) on the 3rd floor tried to touch her about a week ago in between her legs; heard he has done this to other people before; does not feel comfortable riding the elevator with [Resident #2] - Employee #6's (Social Worker) name, indicating that she was the person conducting the resident interview/assessment During a face-to- face conference on 11/14/23 at 12:48 PM, Employee #1 (Administrator), Employee #3 (Clinical Director) and Employee #4 (Regional Clinical Director), Employee #5 (Quality Nurse) were shown the Resident Interview/Assessment Form and asked what was done about Resident #1's allegation of sexual abuse. All four employees reviewed the form and all four stated that they were not aware that Resident #1 had made an allegation of abuse until just now, when the form was presented to them. Resident #1 reported to Employee #6 on 11/10/23 an allegation of sexual and four days after the incident was reported, the incident still had not been reported to facility administration or the State Agency. During a face-to-face interview on 11/14/23 at 1:00 PM, Employee #6 stated that when a resident reports an allegation of abuse to her, she then reports it to her supervisor. When asked if she reported Resident #1's allegation of abuse to her supervisor, Employee #6 stated, No. I don't have a direct supervisor right now to report to. I did the interview of the resident and handed the form, along with other resident interview forms to [Employee #5; Quality Nurse]. When asked if she made Employee #5 aware of the allegation made by Resident #1 when she handed her the form on 11/10/23, Employee #6 stated, No. During a review of employee human resource files on 11/15/23, it was noted that Employee #6, #7 (Social Worker) and #8 (Social Worker) had active Licensed Graduate Social Work (LGSW) licenses for the District of Columbia (DC). During a face-to-face interview on 11/15/23 at 9:48 AM, Employee #7 stated that she reported to the Director of Nursing (DON), Employee #2. The employee further stated, [Employee #2] supervises my work as well as the other social workers. During a face-to-face interview on 11/15/23 at 10:10 AM, Employee #8 (Social Worker) stated that she officially started last week, is in orientation, and still learning about the facility policies and procedures. The employee also stated, I report to the DON. That is what I was told during my initial training. A face-to-face conference was conducted on 11/15/23 at 12:06 PM, with Employees #1 (Administrator), #2 (Director of Nursing), and #4 (Regional Clinical Director). Employee #1 stated that the facility currently has three (3) social workers who report to and are being supervised Employee #2. Employee #1 stated that since 10/09/23, there has been no LICSW in the building to oversee or supervise the three LGSWs that are working in the facility. Employee #1 further stated, The previous LICSW was [officially] terminated on 10/19/23. We tried to contract out a LICSW and were unsuccessful. They had hired one as permanent staff but, last minute, that person decided to not take the job. Someone was hired as of yesterday, and that person is going through the background check and pre-employment process. When asked who supervises the work of the facility's three social workers, Employee #1 stated, They (Social Workers) report to [Employee #2], the DON. When asked if Employee #2 holds an active Licensed Independent Clinical Social Work (LICSW) license, both Employees #1 and #2 stated, No. Review of an Employee Discipline Report dated 10/19/23 documented: - [Name of former LICSW] - Current Action - Termination - Signature of Human Resources and Employee #1 both dated 10/19/23. The evidence showed that from 10/19/23 to 11/15/23, 27 days, there was no documented evidence that the facility employed a full time Licensed Independent Clinical Social Worker (LICSW) to provide oversight and supervision of the Licensed Graduate Social Workers. These failures resulted in an Immediate Jeopardy (IJ) being identified on November 15, 2023, at 5:27 PM. The facility's Administrator provided a corrective action plan to the Survey Team that was accepted on November 15, 2023, at 8:46 PM. The plan included: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. The Administrator has received a contract for Licensed Independent Clinical Social Worker (LICSW) on 11/15/23 who will be starting on 11/16/2023. The LGSW's in the facility were educated by the Administrator on reporting, investigating, protecting, and implementing timely plans of action to mitigate the likelihood of potential further sexual abuse or adverse events. Education provided on 11/15/2023. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. LGSW's will be educated on 11/16/2023 by contracted consultant regarding meeting the resident's behavioral health needs by advocating and assisting residents in the assertion of their rights within the facility in accordance with 483.12, Freedom from Abuse, Neglect, and Exploitation. The facility has contracted with a Licensed Independent Clinical Social Worker (LICSW) on 11/15/2023 who will make facility visits and provide oversight, supervision of the LGSW starting on 11/16/2023. A checklist has been developed to ensure that all abuse investigation documents are reviewed daily from initiation to completion of the investigation. The (LICSW) will conduct random interviews of 10% of current residents to assess whether they have been assisted with advocating their rights within the facility related to being free from Abuse, Neglect, and Exploitation. Audits will be done weekly x 4 weeks then monthly x 2 months. Any findings will be addressed immediately. The Regional Social Services consultant or designee will review the audit results, and findings monthly and will be reported at the monthly QAPI meeting. Verification of the removal of the immediacy was performed by the survey team onsite on November 17, 2023, at 1:53 PM. Cross Reference 22B DCMR Sec. 3229.1

Based on record reviews and staff interviews, facility staff failed to provide appropriate social services to meet resident's needs as evidenced by failing to advocate and assist one (1) of 17 sampled residents in the assertion of their rights within the facility, and to have immediate, direct supervision of Licensed Graduate Social Workers (LGSW) by a Licensed Independent Clinical Social Worker (LICSW). This failure had the potential to affect all residents of the facility. The census on the first day of the survey was 294. Due to these failures, an Immediate Jeopardy (IJ) was identified on November 15, 2023, at 5:27 PM. The facility's Administrator provided a corrective action plan to the Survey Team on November 15, 2023, at 8:46 PM, while the team was on site and the plan was accepted. Verification of the removal of the immediacy was performed by the survey team onsite on November 17, 2023, at 1:53 PM. After removal of the immediacy, the deficient practice remained with the potential for more than minimal harm for all remaining residents at the scope and severity of F. The findings included: Review of the facility's Social Services policy dated 07/26/23 documented: - The facility will provide medically related social services to each resident, to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. - Services to meet resident's needs may include: advocating for residents and assisting them in assertion of their rights within the facility; assisting residents in voicing and obtaining resolutions to grievances. Review of a Resident Interview/Assessment form dated 11/10/23 at 3:13 PM documented the following: - Resident #1's name - Has any resident touched you or tried to kiss you without your consent - Yes - If the response is yes to other question, please describe: [Resident #2] (dark skin) on the 3rd floor tried to touch her about a week ago in between her legs; heard he has done this to other people before; does not feel comfortable riding the elevator with [Resident #2] - Employee #6's (Social Worker) name, indicating that she was the person conducting the resident interview/assessment During a face-to- face conference on 11/14/23 at 12:48 PM, Employee #1 (Administrator), Employee #3 (Clinical Director) and Employee #4 (Regional Clinical Director), Employee #5 (Quality Nurse) were shown the Resident Interview/Assessment Form and asked what was done about Resident #1's allegation of sexual abuse. All four employees reviewed the form and all four stated that they were not aware that Resident #1 had made an allegation of abuse until just now, when the form was presented to them. Resident #1 reported to Employee #6 on 11/10/23 an allegation of sexual and four days after the incident was reported, the incident still had not been reported to facility administration or the State Agency. During a face-to-face interview on 11/14/23 at 1:00 PM, Employee #6 stated that when a resident reports an allegation of abuse to her, she then reports it to her supervisor. When asked if she reported Resident #1's allegation of abuse to her supervisor, Employee #6 stated, No. I don't have a direct supervisor right now to report to. I did the interview of the resident and handed the form, along with other resident interview forms to [Employee #5; Quality Nurse]. When asked if she made Employee #5 aware of the allegation made by Resident #1 when she handed her the form on 11/10/23, Employee #6 stated, No. During a review of employee human resource files on 11/15/23, it was noted that Employee #6, #7 (Social Worker) and #8 (Social Worker) had active Licensed Graduate Social Work (LGSW) licenses for the District of Columbia (DC). During a face-to-face interview on 11/15/23 at 9:48 AM, Employee #7 stated that she reported to the Director of Nursing (DON), Employee #2. The employee further stated, [Employee #2] supervises my work as well as the other social workers. During a face-to-face interview on 11/15/23 at 10:10 AM, Employee #8 (Social Worker) stated that she officially started last week, is in orientation, and still learning about the facility policies and procedures. The employee also stated, I report to the DON. That is what I was told during my initial training. A face-to-face conference was conducted on 11/15/23 at 12:06 PM, with Employees #1 (Administrator), #2 (Director of Nursing), and #4 (Regional Clinical Director). Employee #1 stated that the facility currently has three (3) social workers who report to and are being supervised Employee #2. Employee #1 stated that since 10/09/23, there has been no LICSW in the building to oversee or supervise the three LGSWs that are working in the facility. Employee #1 further stated, The previous LICSW was [officially] terminated on 10/19/23. We tried to contract out a LICSW and were unsuccessful. They had hired one as permanent staff but, last minute, that person decided to not take the job. Someone was hired as of yesterday, and that person is going through the background check and pre-employment process. When asked who supervises the work of the facility's three social workers, Employee #1 stated, They (Social Workers) report to [Employee #2], the DON. When asked if Employee #2 holds an active Licensed Independent Clinical Social Work (LICSW) license, both Employees #1 and #2 stated, No. Review of an Employee Discipline Report dated 10/19/23 documented: - [Name of former LICSW] - Current Action - Termination - Signature of Human Resources and Employee #1 both dated 10/19/23. The evidence showed that from 10/19/23 to 11/15/23, 27 days, there was no documented evidence that the facility employed a full time Licensed Independent Clinical Social Worker (LICSW) to provide oversight and supervision of the Licensed Graduate Social Workers. These failures resulted in an Immediate Jeopardy (IJ) being identified on November 15, 2023, at 5:27 PM. The facility's Administrator provided a corrective action plan to the Survey Team that was accepted on November 15, 2023, at 8:46 PM. The plan included: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. The Administrator has received a contract for Licensed Independent Clinical Social Worker (LICSW) on 11/15/23 who will be starting on 11/16/2023. The LGSW's in the facility were educated by the Administrator on reporting, investigating, protecting, and implementing timely plans of action to mitigate the likelihood of potential further sexual abuse or adverse events. Education provided on 11/15/2023. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. LGSW's will be educated on 11/16/2023 by contracted consultant regarding meeting the resident's behavioral health needs by advocating and assisting residents in the assertion of their rights within the facility in accordance with 483.12, Freedom from Abuse, Neglect, and Exploitation. The facility has contracted with a Licensed Independent Clinical Social Worker (LICSW) on 11/15/2023 who will make facility visits and provide oversight, supervision of the LGSW starting on 11/16/2023. A checklist has been developed to ensure that all abuse investigation documents are reviewed daily from initiation to completion of the investigation. The (LICSW) will conduct random interviews of 10% of current residents to assess whether they have been assisted with advocating their rights within the facility related to being free from Abuse, Neglect, and Exploitation. Audits will be done weekly x 4 weeks then monthly x 2 months. Any findings will be addressed immediately. The Regional Social Services consultant or designee will review the audit results, and findings monthly and will be reported at the monthly QAPI meeting. Verification of the removal of the immediacy was performed by the survey team onsite on November 17, 2023, at 1:53 PM. Cross Reference 22B DCMR Sec. 3229.1

Based on record review and staff interview, for one (1) of 12 sampled residents, facility staff failed to ensure that Resident #8 was free of a significant medication error. This failure resulted in actual harm to Resident #8 on July 19, 2023. The findings included: Review of the facility policy Medication Administration last revised on 05/10/23 documented, .Medications are administered by licenses nurses . as ordered by the physician and in accordance with the professional standards of practice, in a manner to prevent contamination or infection . obtain and record vital signs, when applicable or per physician orders. When applicable hold medication for those vital sounds outside the physician prescribed parameters . Review MAR (medication administration record to identify medication to be administered . Compare medication source (bubble pack, vial, etc.) with MAR to verify resident name medication name form dose route and time. If other than PO (by mouth) route, administer in accordance with facility policy for the relevant route of administration (i.e., injection, eye, ear, rectal, etc.) . Review of the facility's Plan of Correction for the March 9, 2023 recertification survey, with a compliance date of 06/09/23 stipulated, .Licensed professional nursing staff are being educated on the seven rights of medication administration . Random observations will be conducted by unit manager/designee of Licensed professional nursing staff including agency staff to assure that staff is following the seven rights of medication administration . Observations will be weekly x4, then monthly x3 or until compliance is achieved. Any findings and results will be corrected immediately and reviewed by the QA and performance committee. According the Debrox website warning, .When using this product avoid contact with the eyes . https://www.debrox.com/products/debrox-earwax-removal-aid According to the National Institute of Health (NIH), .Nurses have a unique role and responsibility in medication administration . Right drug - ensuring that the medication to be administered is identical to the drug name that was prescribed . Right Route- Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration . https://www.ncbi.nlm.nih.gov/books/NBK560654/ Resident #8 was admitted to the facility on [DATE] with diagnoses that included: Type 2 Diabetes Mellitus, Hypertension, Lymphedema and Anemia. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded the resident as having clear speech, able to make self-understood, and with a Brief Interview for Mental Status (BIMS) summary score of 15, indicating intact cognition. Review of Resident #8's medical record revealed a physician's order dated 04/07/23 that directed, Artificial Tears Ophthalmic Solution 0.2-0.2-1 % . Instill 2 drop in both eyes two times a day for dry eyes. A physician's order dated 07/17/23 documented, Debrox Otic Solution 6.5 % (Carbamide Peroxide). Instill 4 drop in both ears two times a day for Cerumen Impaction for 5 Days. A Situation Background Assessment and Request (SBR) Communication Tool dated 07/19/23 at 11:58 PM: Situation, at about 10:30pm the nurse reported that she accidentally administered ear drop to right eye of the resident . Flushed eyes with normal saline . Assessment: Redness to right eye . Request: ER (emergency room ) transfer . Comments: At about 10:30pm the nurse reported that she accidentally administered ear drop to right eye of the resident .Right eye was red. She complained of burning sensation to right eye. Resident agreed to eye flushing. Both eyes were flushed with normal saline . [Employee #6/Physician] was notified and order was given to transfer resident to the nearest ER (emergency room ) for further evaluation to eyes by ophthalmologist . An Incident Note dated 07/19/23 at 11:59 PM documented: Medication Error: At about 10:30pm the nurse reported that she accidentally administered ear drop to right eye of the resident (Resident #8). Resident refused to talk to this writer. She said, I am upset right now and I don't want to say anything to any of you. Righteye was red. She complained of burning sensation to right eye. Resident agreed to eye flushing .Both eyes were flushed with normal saline. She complained of burning sensation to right. [Primary Medical Doctor's name] was notified and order was given to transfer resident to the nearest ER for further evaluation to eyes by ophthalmologist. 911 was called and resident was transferred to [Hospital name] at 12:05am . A Facility Reported Incident (FRI), DC~12099, received by the state agency on 07/19/23 documented, At about 10:30pm on 7/19/2023 the nurse reported that she accidentally administered ear drop to right eye of [Resident #8]. Eye flushed. PMD (primary medical doctor) gave order to transfer resident to the nearest ER for further eye evaluation by Ophthalmologist. A Hospital Discharge Summary dated 07/20/23 documented: -Patient visit information: You were seen today for: Chemical burn due to acid, conjunctiva, right. -Patient instructions reviewed: chemical eye burns, conjunctivitis, Erythromycin (ointment to treat eye infections), Prednisolone Acetate 1% drops (drops to treat mild to moderate non-infectious eye allergies and inflammation, including damage caused by chemicals). -Additional instructions please follow up with an ophthalmologist within 24 hours. A Nurse Practitioner Progress Note dated 07/21/23 at 10:52 AM documented, Was asked to see pt (patient) for eval (evaluation) of right eye secondary to administration of ear gtts (drops) to right eye. Pt s/p (status post) ER visit - erythromycin ointment and prednisone gtts recommended for right eye chemical burn. Right eye with no erythema, no tearing. Pt denies pain or burning. 'It is better'. No vision loss noted or reported . An Ophthalmology Consult Note dated 07/21/23 documented: -This is a [AGE] year-old female who is being seen for a chief complaint of an itchy eye involving the right eye. -The itching eye is intermittent and new in associated with blurred vision and irritation. -The itching eye is mild in severity right eye worse than left eye. -patient received ear drops in OD (right eye) causing itchiness, but no pain. -Impression/Plan: chemical conjunctivitis OU (both eyes) now resolved. -Continue the following treatment(s): Preservative Free Artificial tears 3 to 4 times a day. -Discontinue the following treatment(s): Erythromycin and Prednisolone Acetate The final facility reported incident received from the facility on 7/24/23 documented the following: On July 19, 2023, at approximately 10:30 pm, an alleged medication error was reported. The nurse, [Employee #9/Registered Nurse], [license number], communicated that she inadvertently administered ear drops in [Resident #8]'s right eye. [Resident #8]'s eye was immediately flushed, and an investigation was initiated. [Resident #8] is a [AGE] year-old female with a BIMs score of 15. Her medical history includes asthma, morbid obesity, DM2 (Diabetes Mellitus), and other comorbidities. [Resident #8] declined to be interviewed. An assessment was completed. [Resident #8]'s right eye was red, and she complained of a burning sensation. Her eye was immediately flushed with saline. The provider was notified. Orders were given to transfer [Resident #8] to the emergency room for additional evaluation and treatment. [Employee #9] was interviewed. She stated that she had ear and eye drops together on the table prior to administering them to [Resident #8]. She admitted that she did not read the label carefully prior to administering the drops to [Resident #8]'s eye. When [Resident #8] complained of a burning sensation, she immediately checked the bottle and discovered the error. She flushed [Resident #8]'s eye with normal saline and contacted the provider. No other witnesses saw [Employee #9] administer medications to [Resident #8]. Nor did they note anything out of the ordinary. Based on the full investigation and witness statements, the facility substantiates that [Resident #8] was administered incorrect medication in her right eye. Follow-up interventions were implemented per facility standards. An initial report was made to the Department of Health via the online portal. The Ombudsman was notified. The provider for [Resident #8] was notified. [Resident #8] was transferred to the emergency room for further treatment and evaluation. [Resident #8] returned on July 19, 2023, with orders to administer ophthalmic steroids and antibiotics. She had no sight loss and denied pain. [Resident #8] followed up with the ophthalmologist on July 21, 2023. No new orders were provided. Per the physician report, her eye showed improvement. [Resident #8] is her own representative and was updated on the plan of care. [Employee #9] was reeducated and counseled for failure to follow the 7 rights of medication administration. A competency check was completed to include an observation of medication administration to verify her understanding and ability to perform the 7 rights per facility standards. She was also given a pre and posttest quiz regarding medication administration. During a telephone interview conducted on 08/24/23 at 9:55 AM, Employee #9 (Registered Nurse/RN) stated that when she went to administer Resident #8's eyedrops, she grabbed the bag that was labeled Artificial Tears Ophthalmic Solution, took out the bottle that was inside and did not check the medication bottle itself prior to instilling it into the resident's right eye. When the resident said that her eye was burning, I checked the bottle and saw that it was the eardrops that were in the eyedrop bag. When asked what the standards of practice are and the facility policy for administration of any medications, Employee #9 stated, I should've have checked the [medication] bottle. It should be noted that a signature representing Employee #9's name was noted on the F760 Residents are free of significant med (medication) errors education sign in sheet dated 5/25/23 that noted, Ensure seven (7) rights of medication administration are followed when administering medication, ensure proper storage of insulin and the process for obtaining medications for medication administration when medication are not available are followed. During a face-to-face interview on 08/24/23 at 10:45 AM with Employee's #1 (Administrator), #2 (Director of Nursing/DON), #3 (Clinical Director), #4 (Quality Nurse), #10 (Educator), they all acknowledged the findings with Employee #10 stating, We will provide more education. Prior to the start of the survey on 08/21/23, the facility took the following steps to correct the identified deficiency: - Employee #9 was educated on 07/20/23 and counseled on the 7 Rights of Medication Administration - Audits of the medication cart starting on 07/2023 to ensure that all residents with an order for ear drops had their proper bag/container with clear markings/directions for their intended use. Cross Reference 22B DCMR Sec 3211.1

Based on observations, interviews, and record reviews, for one (1) of ten (10) sampled residents (Resident #2), facility staff failed to provide adequate supervision and monitoring as evidenced by one resident who left the facility without staff knowledge on 03/19/23 at 3:27 PM, and not ensuring that the wander-guard alarm system was fully functional at all designated doors. An Immediate Jeopardy (IJ) situation was identified on March 22, 2023 at 1:32 PM. On March 22, 2023, at 8:13 PM, the facility provided a corrective action plan that was accepted. On March 23, 2023, at 3:56 PM, the facility provided a revised corrective action plan that was accepted and the immediacy was removed on March 24, 2023 at 4:17 PM. After removal of the immediacy, the deficient practice remained for the potential for more than minimal harm at a scope and severity of D. The findings included: Review of the facility policy titled Elopements and Wandering Residents dated 02/01/22 documented, This facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents .alarms are not a replacement for necessary supervision. Staff are to be vigilant in responding to alarms in a timely manner .Monitoring and managing residents at risk for elopement . interventions to increase staff awareness of resident's risk . adequate supervision should be provided . 1a. Resident #2 was admitted to the facility on [DATE] with diagnoses that included Schizophrenia, Adjustment Disorder with Mixed Anxiety and Depression, Psychosis and Psychoactive Substance Abuse. Review of Resident #2's medical record revealed physician's orders dated 03/25/20 documenting, Place wander-guard on resident. Resident is at risk for elopement every shift, and Charge nurse to document every shift on elopement monitoring. A physician's order dated 08/11/22 instructed staff to, Check wander-guard functionality every evening shift for Elopement. Resident #3's care plan focus area that was last revised on 8/11/22 documented, [Resident #2] is at risk for elopement and the interventions included: check wander guard functioning every evening by the nursing supervisor . document [Resident #2's] attempts to leave the facility. Provide [Resident #2] with picture ID (identification) and place in elopement binder at the front desk. A Quarterly Elopement Risk Evaluation dated 01/23/23 documented, Score - 2.0 .Resident is at risk for elopement (Please proceed to care-plan for elopement and add interventions per facility policy . Resident #2's Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed facility staff coded Resident #2 as having adequate hearing, clear speech, and Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderately impaired cognition. There were no indicators of psychosis or presence of behavioral symptoms and no wandering behaviors exhibited. The resident was noted to be independent with locomotion on and off the unit, no functional impairment in range of motion, no use of mobility devices. The assessment also noted that Resident #2 had received antipsychotic medications on a routine basis and that a wander/elopement alarm was used daily. Situation Background Assessment and Request (SBR) Communication Tool dated 03/19/23 at 8:30 PM documented, Situation: [Resident #2] unable to locate within the facility area at 8:00 pm . According to Weather Underground, the weather on 03/19/23 between 2:42 PM and 3:52 PM in the District of [NAME] was 41 to 42 degrees Fahrenheit with wind gust between 22 to 30 miles per hour (mph). However, at 11:52 PM, temperatures were noted to have dropped to 32 degrees. A Facility Reported Incident (FRI) received by the State Agency on 03/20/23 at 12:36 AM reported, At about 8pm on 03/19/23 resident was observed to be missing from his room and around the unit. Police has been notified and investigation is on- going. Review of the facility's video footage on 03/21/23 at 9:30 AM showed on 03/19/23 at 3:27 PM, Resident #2, wearing a gray, hooded sweatshirt, walked past the wander-guard sensor/alarm device (located on both sides of the hallway, near the glass doors) and through the glass door, which was adjacent to the security reception desk. A female employee [Employee #7/Nursing Supervisor] is seen coming to the wander-guard sensor/alarm device on the left side of the hallway and entering a code. The resident is then seen looking and saying something in the direction of the employee sitting at the front desk [Employee #6/Security Reception Desk Staff], however, the employee was looking down and then he turned to talk to another employee who was behind him, never looking in the direction of the resident or at the main entrance/exit door to see who was entering or leaving. Resident #2 was then seen walking out the main entrance door, veering left, towards 25th Street Southeast, until he was out of view of the camera. Nursing progress note dated 03/20/2023 at 2:11 AM documented, Eloped: At the start of the shift, resident was not in the room as he normally do [every day] like he was sitting on the chair at the first floor [dining] room or by the elevator together with some residents. During medication time writer looks for the resident, and at around 8pm, writer went downstairs to pick him up but [cannot] be found anywhere in first floor dining area, smoking area and in front by the receiving area. Writer asked Costumer service staff [Employee #6] if [Resident #2] left the building and he stated that he did not left. Nursing Supervisor made aware, several staffs went room to room inside the facility but cannot be found. 911 was called . and Police .came to the unit and reports was given, and staffs helped the police to search the facility. Review of the facility's elopement binder, located at the security reception desk on 03/21/23 at approximately 9:15 AM, showed that Resident #2's face sheet, which has his picture, was in the book to alert the reception desk staff that he is an elopement risk. During a telephone interview conducted on 03/21/23 at 11:33 AM, Employee #5 (Registered Nurse assigned on 03/19/23 for 3:00 PM - 11:00 PM shift) stated, When I came in at 3:00 PM, I did my rounds. He (Resident #2) was not in the room. I know him to usually be in the smoking area on the first floor around this time so I was not worried. He is up and down. He would come up for dinner and then go back to the smoking area. I started passing medications at 4:00 PM. Around 8:00 PM, when I went to give him his evening medications, I saw his dinner tray still at the bedside and he was not in the room. I then went downstairs to check the dining and smoking area on the first floor and he was not there either. I asked the front desk if they saw him leave, he [Employee #6] said no. I went to the supervisor and reported that [Resident #2] was missing. We did a room-by-room search and all the closets and floors then notified the Director of Nursing. During a telephone interview conducted on 03/21/23 at 12:01 PM, Employee #6 (Security Reception Desk staff who worked on 03/19/23 from 3:00 PM- 11:00 PM) stated, I worked on Sunday (03/19/23). The [wander-guard] alarm goes off all the time. No one really reacts to it because it's constantly going off. I don't remember the alarm going off, seeing or speaking to [Resident #2] at 3:27 PM. I don't know him or what he looks like. 3 -3:30 [PM] is the change of shift and there's a lot going on at that time. During a telephone interview conducted on 03/21/23 at 2:55 PM, Employee #7 (Nurse Supervisor/employee who silenced the alarm) stated, I had punched in but then needed to go move my car. I heard the [wander-guard] alarm go off as I was walking out. I silenced it. The residents in the smoking area are always walking by and setting off the alarm. I saw [Resident #3 - who also has a wander-guard)] in the hallway and thought it was him that had set off the alarm. I did not check the reception area to see if any residents were there. After I silenced the alarm, I walked outside to move my car. I don't remember seeing any residents walking outside. I am not familiar with [Resident #2]. I am fairly new and don't know who all the wanderers are. 1b. On 03/22/23 at 10:58 AM, a systems check was conducted with Employee #8 (Maintenance Director) of the five (5) wander-guard alarms, all located on the first floor. The system was set-up to alarm (beep) and light up on the two panels (one located at the security reception desk and one at the 1 North nurse's station) show the location of the alarm. It was determined that the system was not fully operational as evidenced by: -When the 1 North, G wing wander-guard alarm was set off, the panel located at the 1 North nurse's station failed to alarm (beep). -When the 1 South, C wing wander-guard alarm was set off, the panel located on the 1 North nurse's station failed to indicate the location of the alarm. It should be noted that during these noted door failures, there were 25 residents deemed at risk for elopement still in the facility, of which 18 wore a wander-guard alarm. During a face-to-face interview conducted on 03/22/23 at 12:14 PM, Employee #2 (Director of Nursing) stated, There is no protocol in place for if a wander-guard alarm is going off for extended period [over 1 minute]. I am not sure if it is written in the policy, but we tell the reception staff that when the wander-guard alarm at the reception desk goes off, they are to immediately lock the main entrance/exit door. Based on these findings, on March 22, 2023, at 1:32 PM, an Immediate Jeopardy (IJ) situation was identified. On March 22, 2023, at 8:13 PM, the facility's Administrator provided a corrective action plan to the State Agency Survey Team with a completion date of 3/22/23, which included: 1. Elopement and wandering residents policy and protocol was reviewed/revised. 2. The DON (Director of Nursing) or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place. 3. Maintenance Department will check total of 8 delay egress and wander guard door and also 2 enunciator panels daily. 4. A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings. All findings will be discussed at the monthly QAA meeting for a minimum of three months or until the pattern of compliance is maintained. 5. Facility will assign total of two staff every shift until upgraded wanderguard system is fully functional and tested for the front reception area, to monitor phone lines and doorways (entrance/exit). One to monitor the phones, the other to monitor entrance and exits to and from facility. 6. All staff will visualize pictures in elopement book daily to familiarize themselves with residents at risk of elopement. 7. New monitoring system (camera) for front hallway to increase monitoring of residents, visitors, and staff. The State Agency Survey Team returned to the facility on [DATE], to verify that the plan of correction was in place. During a face-to-face interview conducted on 03/23/23 at 1:33 PM, Employee #1 (Administrator) stated, Through implementation of the action plan, it was not feasible to ensure that 'All staff will visualize pictures in elopement book daily.' The action plan submitted on March 22, 2023, at 8:13 PM will need to be revised. On March 23, 2023, at 3:56 PM, the facility's Administrator provided a revised corrective action plan which included: Completion date: 3/23/23 . [Numbers 1-5 and 7 were not revised] 6. Receptionist staff will visualize pictures in elopement book daily to familiarize themselves with residents at risk of elopement. All staff will visualize pictures in elopement book monthly to familiarize themselves with residents at risk of elopement. On March 24, 2023, at 4:17 PM, the State Agency Survey Team verified that the plan of correction was in place and had been implemented. The Immediate Jeopardy was lifted at that time. Cross Reference: 22 B- DCMR sec. 3211.1

Based on review of a facility reported incident, medical records, facility documentation, and interviews with family members and staff, for four (4) of 101 sampled residents, the facility's staff failed to 1. safely administer medications in accordance with Standard of Practice or Manufactures Specifications as evidenced by (1) Employee #22 (Agency Registered Nurse; RN) administered one unit of Novolog R insulin to Resident #313 without a physician's order on [DATE], (2) Employee # 25 (Agency RN) signed that he administered medication to Resident #494 who had no medication in the facility, (3) Employee #11 (RN) administered Resident #5 a deceased resident's (Resident #488) medication (Gabapentin), and (4) storing and administering expired Humalog (Lispro) insulin medication to Resident # 7. Due to these failures, an Immediate Jeopardy situation was identified on February 17, 2023, at 4:17 PM. The facility submitted a Plan of Action to the survey team that was on onsite at 2:21 AM on February 18, 2023, and the plan was accepted. The survey team returned on February 21, 2023, to validate the facility's plan, and the Immediate Jeopardy was lifted on February 22, 2023, at 6:40 PM. After removal of the immediacy, the deficient practice remained at a potential for harm and the scope and severity was lowered to an E. The findings included: 1. As per the National Institute of Health, Nursing Rights of Medication administration [Last updated on [DATE]], documented, Nurses have a unique role and responsibility in medication administration, in that they are frequently the final person to check to see that the medication is correctly prescribed and dispensed before administration.it is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' . The five traditional rights of medications administration included: Right patient - ascertaining that a patient being treated is, in fact, the correct recipient for whom medication was prescribed. Right drug - ensuring that the medication to be administered is identical to the drug name that was prescribed. Right Route - Medications can be given to patients in many different ways, all of which vary in the time it takes to absorb the chemical, time it takes for the drug to act, and potential side-effects based on the mode of administration. Right time - administering medications at a time that was intended by the prescriber. Often, certain drugs have specific intervals or window periods during which another dose should be given to maintain a therapeutic effect or level. Right dose - Incorrect dosage, conversion of units, and incorrect substance concentration are prevalent modalities of medication administration error. https://www.ncbi.nlm.nih.gov/books/NBK560654/ A review of the facility's policy titled, Medication Administration dated [DATE] revealed the staff was to Identify residents by photo in the MAR (Medication Administration Record) .review MAR to identify medication to be administered .compare medication source (bubble pack, vial, etc.) with MAR (Medication Administration Record) to verify resident name, medication name, form, dose , route, and time .administer medication as ordered .sign MAR after administered . correct any discrepancies and report to the nurse manager . As per NovoLog fact sheet, NovoLog is a man-made insulin used to control high blood sugar in adults and children with diabetes mellitus. https://www.mynovoinsulin.com/insulin-products/novolog/home.html#:~:text=NovoLog%C2%AE%20is%20a%20rapid,with%20a%20long%2Dacting%20insulin. Resident #313 was admitted on [DATE]. A review of the resident's medical record revealed the resident had the following diagnoses: Parkinson's Disease, Neurocognitive Disorder with Lewy Body, Adjustment Disorder with Anxiety, Dementia, Aftercare following Surgery of Skin and Subcutaneous Tissue, Dysphagia-Oropharyngeal Phase, Cognitive Communication Deficit, Difficulty Walking, Generalized Muscle Weakness, Unspecified Elevated [NAME] Blood Cell Count, Unspecified Thrombocytosis, Essential Primary Hypertension, Constipation, Bradycardia, Pressure Ulcer of Sacral Region (Stage 4). The medical record lacked documented evidence that the resident had a diagnosis or history of Diabetes Mellitus. Review of the resident's medication orders from [DATE] to [DATE] showed the following (active) medications were ordered for the resident: Active Medications -Percocet tablet ,d+[DATE] - give 1 tablet by mouth every 8 hours as needed for chronic sever pain (,d+[DATE]) (start date [DATE]). -A-1000 (Vitamin A) capsule 3 mg (milligrams)- give 1 capsule by mouth one time a day for supplement (start date [DATE]). -Amlodipine Besylate tablet 10 mg - give 1 tablet by mouth one time a day for hypertension (start date [DATE]). -Ascorbic Acid tablet 500 mg - give 1 tablet by mouth two times a day for Parkinson's Disease (start date [DATE]). -Carbidopa-Levodopa tablet ,d+[DATE] mg - give 1 tablet by mouth three times a day for Parkinson's Disease (start date [DATE]). -Rivastigmine Patch 24-hour 4.6 MG/24HR (hour)- apply 1 patch transdermally one time a day for Dementia (start date [DATE]). -Vitamin E capsule 180 mg (400 unit) - give 1 capsule by mouth one time a day for supplements (start date [DATE]). -Mirtazapine tablet 7.5 mg - give 1 tablet by mouth at bedtime for appetite stimulant (start date [DATE]). -Dextrose with Sodium Chloride Solution ,d+[DATE].45% times 3 liters every shift ([DATE]). A Facility Reported Incident (FRI) dated [DATE] (DC00011664) documented, On February 10, 2023, at approximately 7:46 PM an alleged medication error was reported. It was communicated that agency (contracted staff) nurse [Employee #22] obtained [Resident #313's] blood sugar level and administered 1 unit of Novolog R [insulin] without a doctor's order .A nurse completed a full assessment. There was no evidence of hypoglycemia .The provider was notified. New orders were given to check [Resident's name blood sugars every 6hrs (hours) and obtain vital signs every 4hrs for two days. Prior to the incident, [Resident #313] was receiving D5 ,d+[DATE] at 75cc/hr (cubic centimeter/ hour) due to poor intake. [Resident 313] has not shown any signs or symptoms of hypoglycemia since the incident occurred. Nor has she shown any other negative outcomes as a result of insulin administration . Based on the full investigation and witness statement the facility substantiates that a medication error occurred . A review of Employee #22's (RN) written Witness statement signed on [DATE] documented, Writer checked FS (fingerstick) of resident (Resident #313) and result was 163 mg/dl (milligram per deciliter). 1 unit of insulin given. The daughter was in the room at the time of the incident. She started questioning when her mother started getting insulin. Writer checked the PCC (Point Click Care - Electronic Medical Record) there was no order [for Novolog R insulin] . During a face-to-face interview on [DATE] at approximately 9:30 AM, Employee #2 (Director of Nursing; DON) stated that Employee #22 administered 1 unit of Novolog R insulin to Resident #313 on [DATE] without a physician order. The DON said Employee #22 was removed from the unit. And the resident was assessed and there were no ill effects from the insulin. In addition, the DON stated that she went to the resident's bedside and apologized to the daughter on [DATE]. During a telephone interview conducted starting at 9:50 AM on [DATE], the resident's daughter stated, The nurse (Employee #22) came into the room and pricked my mom's finger. I asked the nurse why she pricked my mom's finger. The nurse said she was checking my mother's blood sugar level. When she checked my mom's blood sugar, she said it was 163, which was slightly high. My friend who was with me said to the nurse that my mom just finished eating, that's why her blood sugar was high. The nurse said it wouldn't affect her because she's only getting 1. I can't remember if the nurse informed me, she gave 1 milligram or 1 unit. 2. On [DATE], for Resident #494, Employee #9 (Agency RN) failed to safely administer medications as evidenced by not following: special instructions (hold for diastolic blood pressure less than 60 millimeters of mercury) when administering Hydralazine and Carvedilol; Standards of Practice by not ensuring Resident #494 received the prescribed dose of Hydralazine (anti-hypertensive medication); and Standards of Practice by documenting medications as being administered that were not administered. As per the National Institute of Health, Quality Indicators for Safe Medication Preparation and Administration. A Systemic Review [Published on [DATE]] documented, To ensure safe medication preparation and administration, nurses are trained to practice the 7 rights of medication administration: right patient, right drug, right dose, right time, right route, right reason, and right documentation. However, adhering to these 7 rights is not just the responsibility of the individual nurse, but also of the health care organization . https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4401721/#:~:text=To%20ensure%20safe%20medication%20preparation,documentation%20%5B12%2C%2013%5D. Resident #494 was readmitted to the facility on [DATE]. The resident had multiple diagnoses including Essential Hypertension, Cerebral Infarctions without Residual Deficit, Alcohol Abuse, and Anemia. 2a. Employee #25 (Agency RN) failed to follow special instructions (hold for diastolic blood pressure less than 60 millimeters of mercury) when administering Hydralazine and Carvedilol for Resident #494. On [DATE] at approximately 10:00 AM, a review of Resident #494's electronic Medication Administration Record (MAR) revealed Employee #25 administered Resident #494 Hydralazine 25 mg (milligrams) and Carvedilol 6.25 mg at 8:00 AM. Further review of the MAR revealed the resident's diastolic blood pressure was 56. Review of the resident's medical record revealed the following physician orders, Hydralazine 25 mg -give 1 tablet by mouth every 8 hours for HTN (hypertension). Hold for SBP (systolic blood pressure) < 110 mm/HG (millimeters of mercury) - DB/P (diastolic blood pressure) < 60 mm/HG. Carvedilol 6.25 mg - give 1 tablet by mouth two times a day for heart attack prevention Hold for SBP (systolic blood pressure) < 110 mm/HG (millimeters of mercury) - DB/P (diastolic blood pressure) < 60 mm/HG. During a face-to-face interview on [DATE] at approximately 10:30 AM, The surveyor asked Employee #25 why did he administer the resident Hydralazine 25 mg (milligrams) and Carvedilol 6.25 mg when his diastolic blood pressure was less than 60? Employee #25 failed to provide an answer. On February 10, 2023, at approximately 10:40 AM, Resident #494 was observed in his room lying in bed. The resident was alert and oriented to name, date, and place. A review of Resident #494's vital signs sheet revealed the resident's diastolic blood pressure ranged from 56mm/HG to 78 mm/HG on [DATE] from 8:56 AM to 9:59 PM. 2b. Employee #25 (Agency RN) failed to Follow Standards of Practice as evidenced by not ensuring Resident #494 received the prescribed dose of Hydralazine (anti-hypertensive medication). An observation of Unit 2 North's Team III's medication cart [DATE] starting at approximately 10:00 AM revealed Resident #494's section did not have any medications. At the time of the observation, the surveyor reviewed the resident's electronic Medication Administration Record that showed Employee #25 administered Hydralazine 25 mg on [DATE] at 8:00 AM. Employee #25 was asked by the surveyor, how he administered Hydralazine to Resident #494 if there were no medications in the resident's section of the cart. Employee #25 stated, I use another resident's Hydralazine. The employee then showed the surveyor the other resident's blister pack of Hydralazine 50 mg. The surveyor asked Employee #25 did he administer 50 mg of Hydralazine because 25 mg was ordered. The employee said, No, I gave 25mg. The employee then proceeded to remove an unscored hydralazine 50 mg tablet (that was not scored with a mark indicating where to split it) from the other resident's blister pack. Employee #25 used his hands to break the tablet into two pieces. The tablet was not broken evenly. The surveyor asked, how did he ensure the resident received the prescribed dose, if the pieces of the tablet were not broken evenly. Employee #25 failed to provide an answer. In addition, Employee #25 was asked if he could have retrieved the Hydralazine from the facility's stock medication system. Employee #25 stated, Yes, but because I'm an agency nurse I don't have a code to use the system. I must ask the supervisor, unit manager or a staff nurse to get the medication for me. Review of the resident's medical record revealed the following a physician order, Hydralazine 25 mg -give 1 tablet by mouth every 8 hours for HTN (hypertension). Hold for SBP (systolic blood pressure) < 110 mm/HG (millimeters of mercury) - DB/P (diastolic blood pressure) < 60 mm/HG. Per the Food and Drug Administration, Best Practices for Tablet Splitting, documented, When considering whether to split a tablet, you and your healthcare professional should bear in mind the following: If a tablet is FDA-approved to be split, this information will be printed in the HOW SUPPLIED section of the professional label insert and in the patient package insert. Also, the tablet will be scored with a mark indicating where to split it. If a tablet does not include such information in the label, FDA has not evaluated it to ensure that the two halves of a split tablet are the same in weight or drug content or work the same way in the body as the whole tablet. You should discuss with your healthcare professional whether to split this type of tablet. https://www.fda.gov/drugs/ensuring-safe-use-medicine/best-practices-tablet-splitting Review of the HOW SUPPLIED section of the professional label insert for Hydralazine Hydrochloride lacked documented evidence on how to split Hydralazine tablets. https://www.accessdata.fda.gov/drugsatfda_docs/label/,d+[DATE]s068lbl.pdf An observation of Unit 2 North's Omnicell on [DATE] at approximately 10:30 AM revealed the system contained Hydralazine 25mg tablets. However, the system failed to show the medication was removed for Resident #494. During a face-to-face interview on [DATE] at approximately 10:35 AM, Employee #24 (RN/ Unit Manager) stated that Employee # 25 was not given Resident #494 another resident's medication. He should have asked her or the supervisor to remove it from the Omnicell. 2c. Employee #9 (Agency RN) failed to follow Standards of Practice for Resident #494 on [DATE] as evidenced by documenting medications as being administered that were not administered. An observation of Unit 2 North's Team III's medication cart on [DATE] starting at approximately 10:00 AM revealed Resident #494's section was empty. During a face-to- face interview at the time of the observation, Employee #24 (RN-Unit Manager) stated that the resident was readmitted on afternoon of [DATE]. The resident medication had been ordered from the pharmacy, but the medication had not been delivered to the facility. A review of the resident's electronic Medication Administration Record at the time of the observation revealed Employee #25 (Agency RN) initialed several medications indicating that he had administered the medications listed below as followed: Aspirin [non-steroidal anti-inflammatory drug] 81 mg (milligrams) one tablet, Multivitamin [vitamin] adult one tablet, Nifedipine ER (extended release) 30 mg one tablet, Potassium Chloride [electrolyte supplement] ER 20 MEQ (milliequivalents) one tablet, Thiamine [vitamin] HCI (hydrochloride) 100 mg one tablet, Valsartan [angiotensin II receptor blocker] 80 mg one tablet, Carvedilol [beta blocker]6.25 mg one tablet, Heparin Sodium[anticoagulant] 5000 unit/ml (milliliter) one vial intramuscularly, and Hydralazine [vasodilator] HCI 25 mg one tablet. During a face-to-face interview on [DATE] at 10:50 AM, Employee #25 stated that he only administered Hydralazine and Carvedilol. When asked, how did he give the resident blood pressure if the resident did not have medication in the cart, Employee #25 stated, I used other residents' medications because the resident asked for [pro-[NAME]] blood pressure medication. When asked, why did he initial that he had administered the other medications, he said, I signed in error, but I only gave Hydralazine and Carvedilol. 3. The facility's staff failed to ensure Resident #224 did not receive a deceased resident's [Resident #488] medication. Resident #224 was admitted to the facility on [DATE] with multiple diagnoses that included: Neuralgia and Neuritis, Hypertension, Muscle Weakness, Seizures, Major Depressive Disorder and Acute Kidney Failure. A review of Resident #224's medical record revealed a Physician's Order dated [DATE] that documented Gabapentin Capsule 300 MG (milligrams) Give 1 capsule by mouth one time a day for Neuropathic Pain. A review of Residents #224's February 2023 Medication Administration Record (MAR) revealed the following order, Gabapentin Capsule 300 MG (milligrams) - give 1 capsule by mouth one time a day for Neuropathic Pain at 9:00 AM. Continued review of the MAR showed staff initials from [DATE] to [DATE] (why not [DATE]) indicating Resident #224 was administered Gabapentin at 9:00 AM on the aforementioned dates. An observation on [DATE] at 10:16 AM of Unit 2 South's Team 1's medication cart revealed Resident #224's assigned section contained Resident #488's blister pack of Gabapentin 300 milligrams. During a face-to-face interview on [DATE] at 10:16 AM, Employee #34 (RN) was asked why Resident #488's Gabapentin blister pack was in Resident #224's assigned medications section. The employee stated, I'm not sure, but I know that it's his [medication]. The employee was then asked did she administer Resident #224's Gabapentin 300 milligrams on this date, [DATE], at 9:00 AM, and Employee #34 said, Yes. During a face-to-face interview on [DATE] at 6:20 PM, Employee #27 (ADON) was asked what processes are in place for nursing staff to ensure there are no medication errors. The employee stated, Beginning of shift change, the nursing staff check all medication carts to make sure medications aren't mixed with other residents. 4. The facility's staff failed to follow Manufactures specifications for storing and administering expired Humalog (Lispro) insulin medication for Resident #7. Review of the manufacturer's specifications for Humalog (Lispro), section Storage and Handling, documented, Do not use after the expiration date . In-use insulin Lispro vials . must be used within 28 days or be discarded, even if they still contain insulin . https://pi.lilly.com/us/insulin-lispro-uspi.pdf Review of the facility's policy entitled, Medication Errors, dated [DATE], documented, .The facility shall ensure medications will be administered as follows .Per manufacturer's specifications regarding the preparing, and administration of the biological . In accordance with accepted standards and principles . Review of Resident #7's medical record revealed that the Resident was admitted to the facility on [DATE] with diagnoses including: Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis, Traumatic Brain Injury, and Generalized Muscle Weakness. A Physician's Order dated [DATE] at 11:00 AM directed: Insulin Lispro Solution 100 unit/ml, inject as per sliding scale: If ,d+[DATE] =1 unit; ,d+[DATE] = 2 units; ,d+[DATE] = 3 units; ,d+[DATE] = 4 units; ,d+[DATE] = 5 units, Call MD/NP (Medical Doctor/Nurse Practitioner. If blood sugar is less than 60 or over 400, subcutaneously before meals and at bedtime for DM@ (Type 2 Diabetes Mellitus). Review of the Resident's medical record revealed a Quarterly Minimum Data Set (MDS) with an assessment dated [DATE] which documented the resident had a Brief Mental Status (BIMS) Summary Score of, 15, indicating the Resident had intact cognition. The resident was also coded for using insulin. Review of the Resident #7's Medication Administration Record (MAR) for February 2023 showed that staff administered the resident expired insulin on nine (9) occasions after the expiration date of [DATE], as follows: On [DATE] at 8:00 AM - 1 unit of insulin was administered for a blood sugar of 186 mg/dl. On [DATE] at 11:00 AM - 1 unit of insulin was administered for a blood sugar of 167 mg/dl. On [DATE] at 6:00 PM - 2 units of insulin were administered for a blood sugar of 244 mg/dl. On [DATE] at 9:00 PM - 2 units of insulin were administered for a blood sugar of 244 mg/dl. On [DATE] at 6:00 PM - 1 unit of insulin was administered for a blood sugar of 199 mg/dl. On [DATE] at 6:00 PM - 1 unit of insulin was administered for a blood sugar of 167 mg/dl. On [DATE] at 6:00 PM - 1 unit of insulin was administered for a blood sugar of 162 mg/dl. On [DATE] at 9:00 PM - 1 unit of insulin was administered for a blood sugar of 162 mg/dl. On [DATE] at 8:00 AM - 1 unit of insulin was administered for a blood sugar of 167 mg/dl. It should be noted Resident #7's medical record lacked documented evidence that the resident had any adverse effects from receiving insulin during this period. An observation on [DATE] at 4:38 PM on Unit 1 South showed that inside the top drawer of the medication cart labeled Team 1 contained a vial of expired Humalog (insulin) 100 unit/ml (milliliters) that was marked with Resident #7's name. Written on the vial of insulin was an open date of [DATE] and an expiration date of [DATE]. During a face-to-face interview at the time of the observation, Employee # 9 (Registered Nurse) stated that the last time Resident#7 received Humalog (Lispro) insulin was at 8:00 AM on [DATE] for a blood sugar of 167 mg/dL (milligrams per deciliter). During a face-to-face interview on [DATE] at 4:57 PM, Employee #9 (Registered Nurse) stated most insulin vials are used for 28 days once they are opened; unopened insulin vials are stored in the medication refrigerator. When insulin vials are first opened, the Nurse writes the open and expiration dates along with their initials on the bottle. When asked about the vial of insulin labeled with Resident #7's name, the Employee stated, I inspected the medication cart yesterday, and the vial of expired insulin was not there. Employee #9 then searched the unit's medication storage room, the medication refrigerator, and the two other medication carts and did not locate any additional vials of insulin for Resident #7. During a face-to-face interview on [DATE] at approximately 5:00 PM, Employee #23 (1South Unit Manager) stated that one to two (,d+[DATE]) days before a resident's insulin expires, the Nurse reorders a new vial of insulin from the pharmacy. Employee#23 searched the medication refrigerator in the medication storage room for 1 South and did not locate any new or unopened vials of insulin for Resident #7. The Employee reviewed the Resident's February MAR and acknowledged that the nursing staff had documented that insulin was administered to the Resident after [DATE]. The Employee did not provide evidence that a new vial of insulin was reordered for the Resident after [DATE] and made no further comments. Based on these findings, on February 17, 2023, at 4:17 PM, an Immediate Jeopardy (IJ)-J situation was identified. On February 18, 2023, at 2:21 AM, the facility's Clinical Executive Director provided a corrective action plan to the State Agency Survey Team, which was accepted. The plan included: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. (Completion Date: [DATE]). a). Resident R2 [Resident #313] who received the insulin medication was immediately monitored with no adverse effects noted. Resident remained stable. Employee #8 [Employee #22] was educated on the spot on [DATE] for administering insulin without physician order and on the 7 Rights of Medication Administration. Employee #8 [Employee #22] was removed from schedule and facility. Employee #8 [Employee #22] was placed on the Do Not Return List. b). Resident R3 [Resident #494] was evaluated and no negative effect was noted. E9 [Employee #25] was educated on [DATE] about medication administration and Omnicell availability for meds. c). Resident R5 [Resident #224] did not have any adverse effect from med administration; E11 [Employee #34] was- educated on the spot regarding appropriate process for medication not available - for administration and not utilizing medications from a deceased resident. 2. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent any adverse outcome from occurring. (Completions date: [DATE]). -All applicable facility practices related to medication administration, medication storage and/or ordering medications for new admissions were reviewed/revised. -The DON or designee re-educated licensed nurses on facility practices regarding medication administration, medication storage and/or ordering and reordering medications for new admissions and reconciliation guidelines. Education initiated for nurses beginning ,d+[DATE] through compliance date. -The DON or designee will complete corrective action or one-to-one education on above listed topics with licensed nurse(s) identified as being deficient in their practice resulting in this citation. The DON or designee will educate all licensed and contractual nurses who work on ,d+[DATE] through compliance of this plan, on medication administration, ordering medications and reordering medication and disposition of medication guidelines. The DON or designee audited all residents by to identify if any other residents were administered insulin without a physician order and all new admission residents had medications in the cart that was ordered by [DATE]. All deceased residents' medications were return to pharmacy. 3.The audit will continue until compliance can be maintained for 3 consecutive months. 4.The Administrator or designee implemented a QAPI PIP as a means to gather and process information from the audit. Findings will be reported at the monthly QAPI meeting for a minimum of 3 months. Date Facility Asserts Likelihood for Serious Harm no Longer Exists: [DATE] The survey team verified implementation of the plan and the immediate jeopardy was lifted on February 22, 2023 at 6:40 PM. Cross refernece 22B sect. 3211.1(a)

Based on review of a facility reported incident, medical records, facility documentation, and family and staff interviews, for six (6) of 104 sampled residents, the facility's staff failed properly store medications in accordance with Standards of Practice or Medication Manufacturer's Specifications as evidenced by: (1) not ensuring Resident #7's individual medication compartment did not contain expired Humalog (Lispro) insulin. Subsequently, the resident was administered expired Humalog (Lispro) insulin, (2) Employee #34 failed to ensure Resident #224's individual medication compartment did not contain a deceased resident's [Resident #488] medication, Subsequently the resident was administered the deceased resident's medication [Gabapentin], (3) Employee #35 stored Resident #147's Novolog insulin in her uniform pocket, (4). Employee #15 failed to ensure Resident #155's individual medication compartment did not contain Resident #232's medication. (5) Employee #16 failed to ensure Resident #219's individual medication compartment did not contain Resident #95's medication, (6) Employee #17 failed to ensure Resident #6's individual medication compartment contained Resident #116's medication. Due to these failures, an Immediate Jeopardy situation was identified on February 17, 2023, at 4:17 PM. The facility submitted a Plan of Action to the survey team that was on onsite at 2:21 AM on February 18, 2023, and the plan was accepted. The survey team verified implementation of the plan on February 24, 2023, at 12:40 PM and at the immediate jeopardy was lifted. After removal of the immediacy, the deficient practice remained at a potential for harm and the scope and severity was lowered to a E. The findings included: 1. Review of Resident #7's medical record revealed that the Resident was admitted to the facility on [DATE] with diagnoses including Type 2 Diabetes Mellitus, Hemiplegia and Hemiparesis, Traumatic Brain Injury, and Generalized Muscle Weakness. Review of the manufacturer's specifications for Humalog (Lispro), section Storage and Handling, documented, Do not use after the expiration date . In-use insulin Lispro vials . must be used within 28 days or be discarded, even if they still contain insulin . (https://pi.lilly.com/us/insulin-lispro-uspi.pdf) A review of physician's orders dated [DATE] at 11:00 AM directed: Insulin Lispro Solution 100 unit/ml, inject as per sliding scale: If ,d+[DATE] =1 unit; ,d+[DATE] = 2 units; ,d+[DATE] = 3 units; ,d+[DATE] = 4 units; ,d+[DATE] = 5 units, Call MD/NP (Medical Doctor/Nurse Practitioner. If blood sugar is less than 60 or over 400, subcutaneously before meals and at bedtime for DM@ (Type 2 Diabetes Mellitus). During a face-to-face interview on [DATE] at 4:57 PM, Employee #9 (RN) stated that insulin vials are used for 28 days once they are opened. When insulin vials are first opened, the Nurse writes the opened and expiration dates along with their initials on the bottle. When asked about the vial of insulin labeled with Resident #7's name, Employee #9 stated, I inspected the medication cart yesterday ([DATE]), and the vial of expired insulin was not there. Employee #9 then searched the unit's medication storage room, the medication refrigerator, and the two other medication carts and did not locate any additional vials of insulin for Resident #7. An observation on [DATE] at 4:38 PM of Unit 1 South Team 1's medication cart revealed a vial of expired Humalog (insulin) 100 unit/ml (milliliters) that was marked with Resident #7's name. Written on the vial of insulin was an opened date of [DATE] and an expiration date of [DATE]. Cross reference F760. 2. Resident #5 was readmitted to the facility on [DATE] with multiple diagnoses including neuralgia and neuritis. Review of Resident #5's physician's order revealed an order dated [DATE] documenting, Gabapentin 300 mg (milligrams) by mouth one time a day for neuropathic pain. An observation of Team 2's medication cart on Unit 2 south on [DATE] at approximately 10:00 AM revealed Resident #224's medication section included a blister pack of Gabapentin 300 mg belonging to Resident #488. The medication cart lacked evidence of Gabapentin for Resident #224 at the time of the observation. A review of Residents #224's February 2023 Medication Administration Record (MAR) revealed the following order, Gabapentin Capsule 300 MG (milligrams) - give 1 capsule by mouth one time a day for Neuropathic Pain at 9:00 AM. Continued review of the MAR showed Employee #34 initialed that she administered Resident #224 Gabapentin on [DATE] at 9:00 AM. During a face-to-face interview on [DATE] at 10:16 AM, Employee #34 (RN), was asked why Resident #488's Gabapentin blister pack was in Resident #224's assigned medications section. The employee stated, I'm not sure, but I know that it's his. The employee was then asked did she administer Resident #224's Gabapentin 300 milligrams on this date, [DATE], at 9:00 AM. Employee #34 said, Yes. It should be noted Resident #488 was discharged from the facility in December of 2022. Cross reference F 760. 3. Resident #79 was admitted to the facility on [DATE] with multiple diagnoses that included Hyperlipidemia, Hypertension, Type 2 Diabetes, and Morbid Obesity. Review of Resident #79's medical record revealed a physician's order dated [DATE] that documented, Lipitor Tablet 40 MG (milligrams)- give 1 tablet orally at bedtime for Hyperlipidemia. An observation on [DATE] at 10:48 AM of Unit 2 South Team 1's medication cart revealed Resident #79's individual medication section contained Resident #488's opened blister pack of Atorvastatin [lipid-lowering agent] 40 milligrams with five 5 of 30 tablets remaining in the blister pack. During a face-to-face interview on [DATE] at 10:51 AM, Employee #33 (Agency Licensed Practical Nurse; LPN) was asked if she knew why Resident #79's individual medication section contained Resident #488's Atorvastatin. Employee #33 stated, No, I don't know why; I didn't notice it. I didn't give it, I work the day shift, she gets it at night. Employee #33 then reported that Resident #488 was discharged in December [2022] to the hospital, and she believed the resident passed while in the hospital. In addition, the employee could not explain why Resident #488's medication was still in the medication cart on [DATE], and stated, It should not be there. During a face-to-face interview on [DATE] at 6:20 PM, Employee #27 (Assistant Director of Nursing; ADON) was asked what processes were in place for nursing staff to ensure there were no medication errors. Employee #27 reported, Beginning of shift change, they check all medication carts to make sure medications aren't mixed with other residents. 4. Resident #147 was admitted to the facility on [DATE] with multiple diagnoses including Type 2 Diabetes Mellitus. A review of the resident's medical record revealed a physician's order dated [DATE] that instructed, Novolog 100 units/milliliters inject per sliding scale .subcutaneously before meals and at bedtime. An observation on [DATE] at approximately 11:00 AM revealed Unit 2 South's Team #1, Team #2, and Team #3 medication carts did not contain Novolog R insulin for Resident #147. Also, observation of the unit's medication refrigerator lacked evidence of Novolog R insulin for Resident #147. At the time of the observation, Employee #28 (Unit Manger/RN) stated that she did not see Novolog R insulin for Resident #147 in the medication carts or the medication refrigerator. At approximately 11:30 AM on [DATE], Employee #28 came to the conference room and showed the surveyor an open vial of Novolog R insulin for Resident #147. The employee stated, The nurse [Employee #35] had it in her pocket. The nurse said after she administered insulin to the resident, she forgot to put it back in the medication cart. During a face-to-face interview on [DATE] at approximately 4:00 PM, Employee #35 (RN) was asked if it was the Standard of Practice to store insulin in her uniform pocket. The employee stated, No, I just forgot to put it back in the cart. I was so busy. 5. Employee #15 (LPN) failed to ensure Resident #155's individual medication compartment did not contain Resident #232's Sevelamer Carbonate (phosphate binder) medication. On [DATE] at approximately 4:00 PM, an observation of Unit 3 North's Team 2's medication cart revealed Resident #155's individual medication compartment contained Resident #232's blister pack of Sevelamer Carbonate 800 milligrams. At the time of the observation, Employee #15 stated that the medication Sevelamer Carbonate was in the wrong resident's section. 6. Employee #16 (LPN) failed to ensure Resident #219's individual medication compartment did not contain Resident #95's Donepezil (cognition-enhancing) medication. On [DATE] at approximately 4:40 PM, an observation of Unit 3 North's Team 1's medication cart revealed Resident #219's individual medication compartment contained Resident #95's blister pack of Donepezil 5mg. At the time of the observation, Employee #16 stated that they have residents with similar names and that the facility needed to do name alerts. 7. Employee #17 failed to ensure Resident #6's individual medication compartment did not contain Resident #116's Loperamide (anti-diarrheal) medication. On [DATE] at approximately 10:00 AM, an observation of Unit 3 North Team 1's medication cart revealed that Resident #6's individual medication compartment contained Resident #116's Loperamide (anti-diarrhea) 2 mg medication. At the time of the observation, Employee 17 (Agency Licensed Practical Nurse; LPN) stated that that medication Loperamide might have fallen from the top drawer into the wrong resident's section. Based on these findings, on February 17, 2023, at 4:17 PM, an Immediate Jeopardy situation was identified. On February 18, 2023, at 1:00 AM, the facility's Clinical Executive Director provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: 1. Immediate action(s) taken for the resident(s) found to have been affected include: The medication/Novolog R insulin for Resident #147 was not stored properly and a new vial was obtained from the freezer in medication room. Employee #35 was educated on proper storage of medications and not to share or borrow medication from other residents. Resident #224's, Gabapentin was ordered STAT from pharmacy on [DATE] with a limited quantity and reordered [DATE]. Resident #488 was returned to the pharmacy. 2. Identification of other residents having the potential to be affected was accomplished by: The facility has determined that all residents receiving insulin and Gabapentin medications have the potential to be affected. discharged residents will be reviewed for disposition of medications. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: An in-service education program will be initiated by the Director of Nursing or designee with staff and contractual staff (agency) nurses who are working in the facility from [DATE] to [DATE] to address the facility practices regarding the proper storage of medications, obtaining medications from Pharmacy based on MD orders and disposition of medications upon discharge. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: Unit managers or designee will inspect all medication carts and medication refrigerators daily X 2 weeks, then weekly X 2 weeks, then monthly X 3 for all medication: including insulin and Gabapentin medication, to ensure appropriate storage on an on-going basis. Unit Managers or designee will check medications cart to ensure that residents' medications are available based on MD orders and discharged medications are not in the carts. Findings of this audit will be discussed with the clinical IDT during clinical stand down meetings. This plan of correction will be monitored at the monthly Quality Assurance meeting until such time consistent substantial compliance has been met. Corrective action completion date:[DATE]. On February 22, 2023, the facility's Clinical Executive Director provided additional steps of the corrective action plan to the State Agency Survey Team, which included: On [DATE], the facility has taken the fooling addition steps to remove the IJ for F761: -Nurses, including contractual nurses, who haven't received the in-services in person, continues to receive the education when they are onsite. -Clinical Executive Director, Director of Nursing and QA Nurse discussed the in-services' content to detailed in the Plan of Correction/Allegation of Compliance forms to formulate a competency posttest to test for retention of education provided. -Clinical Executive Director developed the competency test. -QA Nurse or designee is leading the effort to ensure that all licensed nurses who are scheduled to provide direct nursing care on ,d+[DATE] and ,d+[DATE] completes the test. -Education will be given by a clinical leader and/or Staff Development Coordinator for any questions that were answered incorrectly. -Competency test will continue to be given until 100% of licenses nurses are completed, including Nursing Administrative leaders and support staff (i.e.: MDS nurses). Date of Compliance: [DATE] On February 23, 2023, the facility's Clinical Executive Director provided additional steps of the corrective action plan to the State Agency Survey Team, which included: -On [DATE], the facility has taken the following additional steps to remove the IJ for the F761 citation observed during the evening hours of [DATE] [23]. -Administrator, Director of Nursing and Clinical Executive Director had an ad hoc meeting to discuss issues found and the root cause of issues. -All med carts were immediately audited to ensure medications were stored in the correct spaces by the clinical management team. -Director of Nursing initiated an investigation with staff members involved. Staff were interviewed. Statements will be obtained. -Facility leadership team developed a new process wherein nurses will validate, at the beginning of their shift, that all residents' medications are stored in the correct section of the cart (i.e., a residents' medication will be placed in their section only). The verification will be documented on the Medication Verification Form. Further, nurses will verify via the Medication Verification Form that medications received from the pharmacy have been placed in the appropriate section in the med cart. The verification form completion will start ,d+[DATE] on [DATE]. -Inservice was initiated on the ,d+[DATE] shift on [DATE] to advise the staff nurses of the new medication verification process and being mindful of where the medication is stored on the cart going forward via SMS communication. Education will be ongoing when the nurses are onsite, on all shifts. -Unit Clerks will be reminded that they must ensure that a name alert sticker is placed on the residents' door name plate and chart to increase the awareness of the staff. Unit Clerks were educated per SMS communication and will continue onsite when they work. -DON contacted the pharmacy to see if there are name alert stickers for the medication blister packs on [DATE]. Pharmacy stated they were not. LNHA is researching other options to achieve this goal. Date of Compliance: [DATE] The survey team verified implementation of the plan while onsite on February 24, 2023, at 12:40 PM and the immediate jeopardy was lifted. Cross reference 22B DCMR sect. 3227.12 and 3227.13 19141

Based on review of medical records, administrative records, facility documentation/policies, and family and staff interviews, for three (3) of 3 sampled discharged residents, the facility's staff failed to ensure residents were safely discharged as evidenced by not providing Residents #332, #585, and #586 with written instructions for discharge medications. In addition, Resident #332 was discharged with Resident #27's Lisinopril (hypertensive medication). These failures have the potential to affect any resident who is discharged from the facility. Due to these failures, an Immediate Jeopardy situation was identified on February 17, 2023, at 4:17 PM. The facility submitted a Plan of Action to the survey team that was on onsite at 2:21 AM on February 18, 2023, and the plan was accepted. The survey team returned on February 21, 2023, to validate the facility's plan, and the Immediate Jeopardy was lifted on February 21, 2023, at 5:45 PM. After removal of the immediacy, the deficient practice remained at a potential for harm and the scope and severity was lowered to a F. Findings included: Review of a policy titled, Discharge Summary dated 02/01/22, documented, A final summary of the resident's status which includes . for residents discharged to their home, the medical record should contain documentation that written discharge instruction were given to the resident and if applicable, the resident representative. These instructions must be discussed with the resident and resident representative and conveyed in language and manner they will understand . Review of Resident #332's medical record revealed Resident #332 was discharged from a local hospital to the facility on [DATE]. The discharge summary revealed diagnoses, including Hypertension, Heart Failure, and Pulmonary Embolism. Discharge medications included acetaminophen, apixaban, atorvastatin, cyclobenzaprine, furosemide, hydralazine, lidocaine topical, losartan, melatonin, metoprolol, pregabalin, and sennosides-docusate. The discharge summary also noted the following allergies: Active and Proposed Allergies Only) aspirin and metformin. Resident #332's monthly Physician Order Sheet for 12/21/22 to 12/30/22 documented the following medications were ordered: -Atorvastatin Calcium (statin) 40 mg (milligrams) give 1 tablet by mouth at bedtime. -Eliquis (anticoagulant) 0.5 mg give 1 tablet by mouth two times a day. -Furosemide (diuretic) 40 mg give 1 tablet by mouth one time a day. -Hydralazine Hydrochloride (vasodilator) 50 mg give 1 tablet by mouth three times a day. -Lidocaine Patch (local anesthesia) 5% apply to left flank area topically every dayshift. -Losartan Potassium (angiotensin receptor blocker)25 mg give 1 tablet by mouth one time a day. -Melatonin (biogenic [NAME]) Capsule 5 mg give 1 capsule by mouth at bedtime. -Metoprolol Succinate (beta blocker) Extended Release 24 hour 50 mg give 1 tablet one time a day. -Pregabalin (anticonvulsants) Capsule 25 mg give 1 capsule by mouth one time a day. -Senna Plus (stimulant laxative) Tablet 8.6-50 mg give 1 tablet by mouth two times a day. -Cyclobenzaprine Hydrochloride (skeletal muscle relaxants) 10 mg give 0.5 tablet by mouth every 8 hours as needed . -Robitussin (antitussive) 12 hour Cough Suspension Extended Release 30 mg/ml (milliliters) give 5mg/ml by mouth every 6 hours as needed . In addition, the physician's order sheet documented the resident had the following allergies: Aspirin and Metformin. A History and Physical assessment dated [DATE] documented that Resident #322 had the following allergies: Metformin and Aspirin. A 5-day minimum data set (MDS) assessment dated [DATE] showed Resident #332's Brief Interview for Mental Status (Bims) summary score was 15, indicating the resident had an intact cognitive status. A 12/29/22 at 3:08 PM Nurse Practitioner Note read, Ask to make patient's prescriptions and Rx (medical prescription) for outpatient PT/OT (physical therapy/occupational therapy) @ (at) [Rehabilitation Hospital's name]. by social services. As per Social service, patient is going to [be] discharge home on 12/30/22. Prescriptions for 30-day medication supply and RX for outpatient PT/OT sent to 2N (north) unit secretary email. A Discharge Nursing Summary Note dated 12/30/22 at 12:59 PM read, Resident discharged home from the facility at 10:30 am. She is alert and oriented X4 (person, place, time, and situation). Oxygenation saturation at 98% on RA (room air), blood pressure 122/69, respiration 18, pulse 85, temperature 98.1 .She ambulates with a walker. She left with her leftover medication in the chart. After care instructions were provided and explained. She verbalized complete understanding . She is self-responsible. The facility's Discharge Planning/Summary Process dated 12/29/22 at 1:07 PM, included, . Level of Consciousness - Alert/fully conscious. Orientation - person, place, time, situation . Nursing Instructions Regarding Discharge - [Resident's name] has been educated on her discharge instructions. [Pro-[NAME]] verbalized complete understanding . Medication Instructions - Printed/written directions have been provided for each of the medications being taken out of the facility. Yes. However, continued review of the medical record lacked documented evidence of the printed/written directions provided to the resident or resident's family. Review of the facility's investigation, revealed the following: The discharging nurse's statement dated 01/04/23 documented, . I explained to [resident and family] who were at the bedside . the aftercare instructions which include (sp) the time and when to take each medication and treatment per doctor's orders. I also her gave [resident's name] all her leftover medications that were in the medication cart per protocol. [Resident's name] and her daughter verbalized understanding of discharge instructions. [Resident's name] told me she used to work here . as a RN. I then provided her with 2 copies of her discharge instructions and told her to go thoroughly through instructions, read it and if she has any questions, I'll provide an answer .I went [back] to her room and asked . if they had any questions. [Resident's name] said, No . A Letter from the Administrator to Resident #332's family dated 01/04/23 read, On January 23, 2023, your [pro-[NAME]] made us aware of a protected health information data breach involving a resident at Capitol City. It seems that when [Resident] was discharged from the facility provided another resident's medication card along with [Resident] medication cards. I apologize for the inconvenience. Please return the medication card to the facility, as it is the property of another resident. If returning to the facility poses a hardship, please shred the portion of the medication card which details the resident name and medication and dispose of the medication . Again, my apologies for the inconvenience. Review of complaint received by the State Agency dated 01/26/23 (DC- 11567) read, On December 13, 2022 . [Resident #332] was released from the nursing home on December 30 [2022], She was given medication (lisinopril) that had been prescribed for someone else (Resident #27). She had an immediate and sever allergic reaction to this medicine . [Resident #332] still remains in the hospital and was in a comatose state for at least a week . In addition, . it was noted in [pro-[NAME]] medical file, that under NO circumstances should [pro-[NAME]] be given this medicine [lisinopril]. [Resident #332] was immediately rushed to [a local hospital]. When I notified the staff at the nursing home of their mistake and [Resident #322's] resultant reaction instead of an apology or show remorse, I was told that it was my responsibility to check the medication and make sure it was not [Resident #322's] and they were not accountable . still remains in the hospital and was in a comatose state for at least a week . During a telephone interview on 02/10/23 starting at 1:30 PM, Resident #332's family members stated that the resident was provided another resident's Lisinopril medication when the resident was discharged on [DATE]. They reported that when they went to pick up the resident for discharge, Employee #4 (LPN; Discharging Nurse) did not meet with them. Instead, the employee gave them paperwork to sign and provided them with a bag of Resident #332's medications. The family members reported, after returning home, they noticed the resident's tongue was swollen after the resident asked if her tongue was swollen. They took Resident #332 to the hospital immediately and was told by hospital staff that she was having an allergic reaction to Lisinopril. The resident's family stated she ended up in ICU, on a ventilator, and in a coma for one week after taking the Lisinopril. The family was asked who administered the resident's medication while at home? They stated that the resident administered her own medication like she did prior to being admitted to the facility. In addition, while speaking with the family members, the resident could be heard in the background answering questions that family members were asking. The surveyor asked if she could speak with the resident, but the resident refused to talk with the surveyor. During a telephone interview on 02/10/23 at 5:17 PM, Employee #4 (LPN) stated that he discharged Resident #332 home with family in December of 2022. The employee stated he verbally explained the discharge instructions including the medication and times when to take the medications to the resident and resident's family. The only written instruction he provided for medication was a copy of the prescriptions. Further interview revealed that Employee #4 gave Resident #332 all her left-over medications in the cart. The employee was asked if he used the prescriptions to check the medications that he gave the family. He stated, Yes, we went one-by-one. The employee was then asked, if he went one-by-one with the prescriptions and medications, how did Resident #332 get another resident's (Resident #27) lisinopril? He stated, I can't explain. The medication was stuck to one of her own medications. My guess it was stuck to her medicine. Also, the employee said it was the facility's protocol to provide resident's being discharged with their medication from the medication cart. The employee was asked if he was aware of the resident's allergies? He said, I can't remember any allergies at this time. During a face-to-face interview on 02/10/23 starting at approximately 5:30 PM, Employee #3 (DON) stated that Employee #4 gave Resident #332 another resident's Lisinopril. Additionally, the DON reported Employee #4 failed to follow the discharge protocol by not asking the supervisor to be involved in discharging the resident. The employee also said the resident should have been provided with written instruction on how to safely administer the prescribed discharge medications at home During a face-to-face interview on 02/13/23 at 3:39 PM, Employee #1 (Administrator) stated that the discharging nurse discharged Resident #332 with Lisinopril that belonged to another resident. He reported that during the first week in January the family made Employee #5 (Quality Assurance) aware that they had another resident's medication card (blister pack) for Lisinopril. Employee #1 stated that he spoke with the family about their concerns and gave them a letter that outlined how to destroy personal health information and medication. When asked, if he was aware the resident was intubated and in ICU, he stated, I don't recall if she was in ICU or on a ventilator. During a telephone interview on 02/13/23 at 2:26 PM, Employee #10 (Medical Director/Resident's #332 Primary Physician) stated that he did not order the resident Lisinopril during her stay at the facility. The Medical Director stated that he was informed that the discharging nurse mixed up another resident's Lisinopril medication with Resident #332's medication. Additionally, the Medical Director stated he was not aware of the resident having an allergy to Lisinopril. He stated he gets allergy information from hospital records. During a face-to-face interview on 02/14/23 at 11:55 AM, Employee #5 (Quality Assurance) stated that on January 2, 2023, Resident #332's two daughters came to the facility and made her aware that the resident was discharged with another resident's Lisinopril. They said the resident was allergic to Lisinopril and they believe she took it. They said that the resident was hospitalized because was she was allergic Lisinopril. Additionally, Employee #5 stated, They (resident's daughters) said [pro-[NAME]] was very ill and they showed me a picture of her and she looked like she was intubated. Additionally, the employee stated that the family showed her the blister packet that belonged to the other resident, and it looked like three (3) of 30 pills were missing from the blister pack. 2. Resident #586 was admitted to the facility on [DATE] with diagnoses that included: Metabolic Encephalopathy, Hyperlipidemia, Acute Kidney Failure, Fracture of Right Femur, and Cognitive Communication Deficit. Review of the resident's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which included a Brief Interview for Mental Status (Bims) summary score of 12, indicating the resident was cognitively intact. A Nursing Progress Note dated 12/27/22 at 9:30 AM read, Resident went home with an escort via Uber, a copy of discharge summary was handed to him with all his belongings . A Discharge Planning Summary/Process dated 12/27/22 at 1:24 PM documented, .Resident is alert and ready to be discharged all due meds given and well tolerated, teaching done and resident understand how to take his meds (medication) . Further review of Resident #586's medical record showed there was no documented evidence that the resident was provided written instructions on how to safely administer the medications that were given to take home at discharge. During a face-to-face interview on 02/16/23 at 03:30 PM, Employee #3 (DON)was asked about the facility's policy pertaining to resident discharges, instructions, and medications. Employee #3 stated that the resident should receive discharge instructions in writing which includes the medication list and any special instruction for medication i.e. taking blood pressure before taking antihypertensive medication. 3. Resident #585 was admitted to the facility on [DATE] with diagnoses that included: Cognitive Communication Deficit, Cerebral Infarction, Dysphagia, Hypertensive Urgency, and Muscle Weakness, Review of Resident #585's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which included a Brief Interview for Mental Status (Bims) summary score of 03, indicating the resident was severely impaired. The Discharge Planning Summary/Process] dated 01/11/23 at 11:27 AM documented .Resident was educated that pharmacy will send [pronoun] medication to [pronoun] house, and how to take it too .Required education & acknowledgement of education: Medication Instructions: Printed/written directions provided for each of the medications being taken out of the facility .a) Yes . A Nursing Progress Note dated 01/11/2023 at 4:32 PM read, Resident was discharged home this morning at 10:45am in stable condition, tolerated due meds, was discharged with [pronoun] belongings, discharge papers, pharmacy will send [pronoun] medication to [pronoun] house, left with RR (responsible representative) who signed the discharge papers. Further review of the resident's medical record showed there was no documented evidence that the resident's representative was provided with written instructions on how to safely administer the medications ordered to be taken at home at time of discharge. During a face-to-face interview on 02/16/23 at 03:30 PM, Employee #3 (DON) was asked about the facility policy pertaining to resident discharges, instructions, and medications. Employee #3 stated that the resident should receive discharge instructions in writing which includes the medication list . Based on these findings, on February 17, 2023, at 4:17 PM, an Immediate Jeopardy (IJ)-J situation was identified. On February 18, 2023, at 2:21 AM, the facility's Clinical Executive Director provided a corrective action plan to the State Agency Survey Team that was accepted. The plan included: -Resident #1 discharged from the facility on 12/30/22. -Resident #9 discharged from the facility on 1/11/23. -Resident #10 discharged from the facility on 12/27/22. -The facility didn't receive any reports from the residents who discharged on [DATE] to 2/17/23 regarding their medications and/or discharge instructions. -The Director of Nursing or other clinical leaders will ensure residents who are scheduled for discharges 2/18-2/20/23 will be at audited to ensure the resident and/or their representative have the correct prescriptions per the provider's order, special instructions for medications for potential complications, side effects and drug interactions. The information will be shared via the medication administration instructions per the titled form, Drug Information Sheets from our electronic health record software. -The discharging nurse will be responsible to ensure that resident teaching regarding medication administration is shared in a manner that is easily understood using the provided, Drug Information Sheets. The discharging nurse will ask the family to express their understanding and/or questions after receiving the teaching via the provided Drug Information Sheets. Audits will be on-going and will be completed by the clinical leaders which will include; but not limited to, the Director of Nursing, the Assistant Directors of Nursing, Unit Managers and other licensed nursing personnel per the auditing schedule. Audits will be completed on the residents' discharge date ; including but not limited to, the weekends and holidays. Education -The Nursing Administration, licensed nurses responsible for discharging residents and social service personnel; including but not limited to, the Director of Discharge Planning, will be educated on the revised discharge protocol which will be to: 1. Ensure the resident and/or their representative has the correct medication prescriptions per the providers' orders. 2. Provide the resident and/or their representative with the physician orders. 3. Give their medication administration instructions to the resident and/or their representative per the Drug Information Sheet from Point Click Care. 4. The discharging nurse will ensure teaching is done in a manner that the resident and/or their representative will easily understand. The discharging nurse will ask the resident and/or their representative if there's any questions about their discharge medication per their prescriptions. The discharging nurse will attempt to answer their questions to the best of their ability. The provider will be contacted if the nurse's answers aren't sufficient. 5. Education was initiated on 1/25/23 and ongoing to the licensed nurses about the facility's discharge protocol revisions. The discharge protocol summary noted, Nurses must review the discharge instructions to ensure follow up information such as appointments, wound care/wound care supplies, current medication list with administration times, acknowledgement of discharge instructions with wet signatures. Discharge protocol will be revised and education given to the licensed nurses to note the systematic changes as of 2/17/23. 6. Education to weekend staff to be provided by either shift supervisor, staff development, a clinical leader and/or the Director of Nursing. Education will be provided either in-person or via phone calls and/or the facility's electronic SMS communication tool. The nursing staff who works in the facility on 2/18, 2/19 and 2/20 will have onsite in-servicing to reinforce the education sent on 2/17/23 via SMS communication tool. There are no scheduled discharged ,d+[DATE], 2/19 or 2/20/23. Staff will not be allowed to work until they have received the required training. System Change -The facility will revise our discharge practices via our discharge protocol that will only send residents home with the physician prescriptions, orders, medication administration instructions via the Drug Information Sheets which includes the content that the licensed nurse can use to provide easily understood teaching. If questions and/or concerns arise, the nurse will attempt to answer the questions. If the answers are not sufficient, the provider will be contacted. Monitoring -The Director of Nursing or designee will audit all discharging residents to ensure that they have the correct medication prescriptions, physician orders, medication administration instructions via the Drug Information Sheets, ensure that resident teaching regarding medication administration is shared in an easily understood manner and questions are answered by the nurse and/or provider weekly x 4, then monthly x 3. Results of the audits will be submitted to the Quality Assurance and Performance Committee. The Committee will determine the need for further and/or action plans. Date of compliance: 2/23/23 Verification of the removal of the immediacy was performed by the survey team onsite on February 21, 2023, at 5:45 PM Cross reference 22B DCMR sect. 3270.3

Based on observations, record reviews, resident, and staff interviews, for one (1) of 98 sampled residents, the facility's staff failed to ensure Resident #255's menu was followed, as evidenced by not providing a pureed diet on 02/17/22. Subsequently, after eating approximately 10% of a biscuit that was provided by facility staff on 02/17/22, the resident complained of feeling the biscuit in his throat. Due to these failures, an Immediate Jeopardy situation was identified on February 17, 2023, at approximately 5:30 PM. The facility submitted a Plan of Action to the survey team that was on onsite at 2:21 AM on February 18, 2023, and the plan was accepted. The survey team verified implementation of the plan on February 21 - 22 2023. The Immediate Jeopardy was lifted on February 22, 2023, at 6:40 PM. After removal of the immediacy, the deficient practice remained at potential for more than minimal harm that is not immediate jeopardy for all remaining residents, at a scope and severity of D. The findings included: Resident #255 was readmitted to the facility on [DATE]. The resident had a history of diagnoses including dysphagia following cerebral infarction, dysphagia oropharyngeal phase, gastro-esophageal reflux disease, acute gastric ulcer without hemorrhage or perforation, dysphonia, and Parkinson disease. 1a. Review of Resident #255's Physician Orders revealed an order dated 01/25/23 documenting, Aspiration precautions every shift. A Nutrition assessment dated [DATE] at 1:07 PM documented, .Puree diet, resident tolerating well, however, prefers upgrade, rec (recommend) slp (speech therapy) screen as needed . A Speech Therapy Note dated 01/30/23 at 4:36 PM documented, Patient seen for skilled dysphagia intervention during lunch . An admission minimum data set with an assessment date of 01/31/23 documented that the resident was coded for coughing or choking during meals or when swallowing medications and complaints of difficulty or pain with swallowing. Resident #255's care plan dated 02/01/23 documented, Focus Area- [Resident's name] has GERD (gastro-esophageal reflux disease) .Interventions - monitor/document/report to MD (medical doctor) PRN (as needed) s/sx (signs/symptoms) of GERD: Belching, coughing/choking when lying down, heartburn, dyspepsia, N/V (Nausea/vomiting) indigestion, regurgitation, increased salivation, swallowing problems, bitter taste in mouth, dysphagia, substernal chest pain, increased gag response. A Speech Therapy Note dated 02/04/23 at 2:52 PM [Speech Therapy Note] documented, Patient seen for skilled dysphagia intervention during lunch. Patient received mechanical soft lunch meal; however, most meal items more consistent with regular texture (rice, chopped chicken, and beans). No sauce or gravy present on tray despite SLP (speech therapy) order on meal ticket. Patient requesting downgrade to puree texture .SLP provided education to nursing on downgrade and will follow up with kitchen management and dieticians . A physician order dated 02/04/23 documented, Regular diet, pureed texture, thin consistency, extra sauce/gravy for all meals including breakfast to moisten food for dysphagia (swallowing difficulties). In addition, on 2/6/23 the physician ordered the following: Follow-up with GI (gastroenterologist) at [hospital's name] oropharyngeal dysphagia . A Speech Therapy Note signed on 02/16/23 at 7:47 AM, documented, Patient seen for skilled ST (speech therapy) services targeting dysphagia .nurse caregiverse (sp) reporting patient complaints of difficulty swallowing .recommend follow-up with GI (gastroenterologist) for further investigation . On 02/17/23 at approximately 8:40 AM, Resident #255 was observed sitting in a chair with a bedside table in front of him. The table had a covered breakfast tray on it. When asked, if he enjoyed his breakfast, he stated, No, I can't eat it because it's not pureed. The resident allowed the surveyor to uncover the tray. The tray included one (1) uneaten hard-boiled egg, one (1) partially (approximately 10%) eaten biscuit, and one (1) carton of 2% white milk approximately 90% consumed. The resident was asked if he ate the biscuit, and he stated, Yes, and I feel like it's stuck in my throat. I've been drinking the milk to push it down, But I still feel it. Review of the tray card that was on the tray documented the resident was to receive a Regular Pureed diet with 2xsmall cups sauce or gravy daily on the side. There was no gravy noted on the resident's meal tray. Employee #2 (DON) was called to the bedside. She reviewed the tray card and said the resident should not have received this diet because it is a regular texture and not pureed texture, as indicated on the tray card. Employee #16 (Dietician) was called to the bedside and asked if the meal the resident had in front of him was safe for him, and she stated, This is not an appropriate diet for a pureed diet. He is being followed by speech therapy. During a face-to-face interview on 02/17/23 at 10:00 AM, Employee #12 (Speech Therapist Clinical fell ow) stated that the breakfast of a hardboiled egg and a biscuit served on 02/17/23 was unsafe for the resident since the resident needed a pureed diet due to a dysphagia diagnosis. 1b. Review of Resident #255's physician orders revealed an order dated 02/04/23 that documented, Regular diet, pureed texture, thin consistency, extra sauce/gravy for all meals including breakfast to moisten food for dysphagia (swallowing difficulties). On 02/21/23 at approximately 8:45 AM, Resident #255 was observed eating breakfast. The texture was pureed however the meal did not have gravy/sauce. Employee #3 (DON), Employee #11 (Dietician), Employee #12 (Speech Therapist Clinical fell ow) were called to the resident's room. They all reviewed the resident's diet order and stated that the resident was to be given gravy or sauce for all meals, including breakfast. However, Employee #13 (Dietary Director) stated that her staff did not add gravy or sauce to Resident 255's breakfast because she thought the order for gravy/sauce on breakfast was an error. Based on these findings, on February 17, 2023, at 4:17 PM, an Immediate Jeopardy (IJ)-J situation was identified. On February 18, 2023, at 2:21 AM, the facility's Clinical Executive Director provided a corrective action plan to the State Agency Survey Team, which was accepted. The plan included: 1. Identification of Residents Affected or Likely to be Affected: The facility took the following actions to address the citation and prevent any additional residents from suffering an adverse outcome. a. All residents that have pureed diets were assessed for any s/s of aspiration and for correct meal consistency by the clinical leadership team. No other reports of residents receiving incorrect diet consistency. b. Administrator and Dietary Leadership team validated all lunch tray consistencies ordered were accurate on meal trays. c. Education was initiated with all nursing and dietary staff in facility per SMS messaging to ensure that the meal tray tickets, and the residents' plates matched. Education will be validated for understanding by onsite education on meal tray and residents' plates matching. (Completion Date: 2/20/23) 2. The Registered Dietitian or clinical leader personnel will conduct an audit to ensure all dietary orders and recommendations are accurate in the medical record and match the dietary department's tray card information for each resident per MD orders by 2/20/23. 3. Actions to Prevent Occurrence/Recurrence: The facility took the following actions to prevent an adverse outcome from reoccurring. (Completion Date: 2/23/23) -Meal tray distribution and practices and practices reviewed/revised. -Education was initiated with dietary and nursing staff by the Clinical Leadership and Dietary Manager/designee regarding applicable facility processes related to meal tray preparation (i.e.: meal ticket and plates match) and distribution, compliance with resident specific dietary interventions, and food preparation consistency with each residents' diet orders. Two nursing staff will check trays prior to deliver to the residents in order to ensure accuracy. -Activities will check PCC for diet order and consistency. Nursing staff ensure will that snacks have a label present that's includes resident name, diet, and consistency. -The Dietary Manager/designee and clinical management leaders will audit new admissions for 3 months to ensure the dietary orders/recommendations/ recommendations/documentation are accurate in the medical record and match the dietary department's tray card information for that resident. -The Dietary Manager or designee will monitor food preparation at all three meals, and compare the meal being prepared to the physician order/documentation for that resident's dietary needs. Monitoring/auditing will continue daily x 2 weeks and weekly x 2 and then monthly x 3. -The DON or designee will monitor food service at all three meals, and compare the meal being served to the physician order/documentation for that resident's dietary needs. Monitoring/ auditing daily x 2 weeks and weekly x 2 and then monthly x 3. -The Administrator or designee implemented a QAPI PIP as a means to gather and process information from the audits/monitoring processes. Findings will be reported at the monthly QAPI meeting for a minimum of 3 months. Date Facility Asserts Likelihood for Serious Harm No Longer Exists: 2/18/23. The survey team verified implementation of the plan and lifted the immediate jeopardy on February 22, 2023, at 6:40 PM. Cross reference 22B DCMR sect. 3211.1(a)

Based on observations, record reviews, and staff interviews for six (6) of 105 sampled residents, the facility staff failed to ensure residents were free from abuse. (Residents #146, #163, #254, #70, #131 and #169.) Actual harm was determined to be present for Residents #169, and #131. The findings included: A review of a policy titled Abuse, Neglect and Exploitation revised on 09/20/22, documented .The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse during and after the investigation. Examples include but are not limited to: Responding immediately to protect the alleged victim and integrity of the investigation. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed: Increased supervision of the alleged victim and residents .Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse .Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional abuse, during and after the investigation .Taking all necessary actions as a result if (sp) the investigation, which may include but are not limited to, the following: Analyzing the occurrence (s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; Defining how care provision will be changed and or improved to protect residents receiving services; .Identification of staff responsible for implementation of corrective actions; 1. Facility staff failed to prevent Resident #169 from repeated episodes of abuse due to inadequate supervision which resulted in physical altercations. Resident #169 was admitted to the facility on [DATE] with multiple diagnoses that included Tobacco Use, Unspecified Dementia, and Altered Mental Status. Review of Resident #169's medical record revealed a care plan initiated on 05/25/22 with a focus area of .[Resident #169] has exhibit (ed) (sp) aggressive behavior while in the smoking patio due to dx (diagnosis) of dementia with behavior disturbance . had the following interventions Monitor for aggressive behavior .psych (psychiatry) consult for medication review . [SBAR (situation background assessment recommendation) -Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool] dated 06/21/22 at 9:06 PM .It was reported to this writer that resident grabbed CNA (certified nurse aide) staff's shoulder at about 6:25 PM .resident was separated and was redirected. On assessment resident was unable to remember what exactly transpired in the dining room on first floor . There was no documented evidence in the medical record that the facility provided interventions in the care plan to address the residents' symptoms of Dementia. A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that the facility staff coded the following: severe cognitive impairment, physical behavioral symptoms directed towards others (e.g., kicking pushing, scratching, grabbing, abusing others sexually) that occurred in 1 to 3 days. The Resident was also coded as having verbal behavioral symptoms directed toward others (e.g. threatening others, screaming at others, cursing at others) occurred in 1 to 3 days. The identified symptoms put the resident at significant risk for physical illness or injury, interfered with the resident's care, put others at significant risk for physical injury, and significantly disrupted care or living environment. The facility staff coded the resident as having no impairment in the upper or lower extremity. Further review of Resident #169's medical record revealed a situation background assessment recommendation (SBAR) -Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool] dated 09/17/22 at 4:54 PM documenting, .It was reported to this nurse that resident hit his roommate [ .] on the head with his walking cane at about 11:45 am. Resident denied hitting his roommate with his cane. Resident refused assessment . An SBAR -Physician/NP (Nurse Practitioner)/PA (Physician Assistant) Communication Tool] dated 10/02/22 at 9:37 AM documented, .[Resident #169] initiated a physical altercation with one of the resident . while in the smoking patio, when he tried to snatch cigarette . A [Nurses Note] dated 10/24/22 at 12:38 PM documented, .Seen [Resident #169] sitting in the chair in the first floor closed (sp) to elevator when ( .) started hitting him in his face and (Resident #169) got up and swung back at him and she redirected [Resident #169] to get on elevator .Assessment was done. No redness or bruise noted on [Resident #169] was noted with a bump on his right left forehead, he complaint (sp) of pain during assessment in scale 4/10. Review of a care plan date initiated 10/24/22, with a focus area of [Resident #169] had resident to resident interaction with (Resident name) 10/24/22 had the following interventions Administer Tylenol (analgesic) 325 mg (milligrams) 2 tabs po (by mouth) prn (as needed) for pain .Apply ice compress x (times) 10 minutes on his forehead every shift x 24 hours .Police was called, no file case was made .Psych (Psychiatry) consult to evaluate . A nursing progress note dated 01/19/23 at 5:02 PM documented, Report received around 2:50 PM resident was involved in a physical interaction with another male resident. Resident sustained minor injury to his right forehead, and right lower leg . A facility-reported incident (FRI) dated 1/19/23 indicated Resident #169 sustained a skin tear to his right lower leg, and abrasion to his right forehead. An additional progress note dated 01/19/23 at 6:51 PM documented, .[Provider Name] was notified and order given as follows , Right forehead abrasion-Cleanse with NSS (Normal Saline Solution) pat dry apply bacitracin (Topical antibiotic ointment ) leave open to air. Right lower leg skin tear- cleanse with NSS (Normal Saline Solution) pat dry .[Resident #169] was interviewed, he stated that the guy punch him on his face and he did not know he hit him and stated that he hit back A FRI submitted to the State Agency on 02/21/23, documented, .On February 16, 2023 at approximately 1:00 PM, an alleged resident to resident physical altercation was reported. It was communicated that residents (Resident #131 and Resident #169) had a heated exchange which resulted in a scuffle while they were out on the smoking patio. The residents were immediately separated. Nursing progress note dated 02/16/23 at 12:26 PM noted, Around 10:49 AM this morning, writer heard loud voices and went towards the voices. On approaching the first floor Dining room, writer observed [Resident #169] on the floor near the vending machine towards the rear of the Dining Room, with [Resident #131] astride him. The residents were separated. There was no apparent injury upon assessment . Review of a care plan revised on 02/18/23, revealed the following focus area: [Resident #169] has a behavior r/t (related to) wandering on the hallways, attempting to enter other resident's rooms/staff offices, invading in roommates space/privacy .has behavior of picking cigarette butt in the smoking patio .Behavior of begging for cigarette from other resident while in smoking patio. The following interventions were noted, administer medications as ordered, anticipate and meet needs, hourly monitoring for safety, Intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Review of a document provided by the facility titled smoking monitors dated 02/23/23, listed Resident #169's name and six other Residents' names stating, When these residents are on the smoking patio or waiting to enter the smoking patio, please monitor them to ensure they do not interact negatively with other residents. During a face-to-face interview conducted on 02/28/23 at 12:55 PM, Employee #18 (Unit Manager 3 South) acknowledged the findings and stated, (Resident #169) was actually asking everyone for a puff of their cigarette. They started tussling (fighting) and ended up on the floor. I asked [Resident #169] what happened, and he had no memory of the altercation .I spoke with the family about the issues. 2. Facility staff failed to prevent an episode of abuse in which Resident #70 and Resident #169 were engaged in a physical altercation. Resident #70 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Disorder of the Brain, Bipolar Disorder, Restlessness and Agitation, Schizoaffective Disorder, and Difficulty Walking. A review the Quarterly Minimum Data set (MDS) dated [DATE] revealed that the facility staff coded the resident as having moderately impaired cognition. Facility staff coded that the resident did not present any symptoms of psychosis or behavioral symptoms and the resident had no impairment of the upper or lower extremity. A Nursing Progress Note dated 10/24/22 at 3:45 PM documented, .[Resident #70] hit another resident while in the hallway. Resident noted with open area to right hand knuckle. When asked what happened resident said he got into an altercation with another resident and punched him. Resident was taken to his unit for assessment. Hand assessed and resident denied pain at site . A review of a Facility Reported Incident (FRI) submitted to the State Agency on 10/24/22 documented .Report received that this morning around 8.40 AM, resident hit another male resident [Resident #169]. [Resident #169] refused assessment. It in (is) unknow (sp) where [Resident #169] was hit as [Resident #70] did not disclose. Observed [Resident #70] with open area to his right knuckle area. [Resident #70] admitted to hitting [Resident #169] because [Resident #169] sat in a chair belonging to another resident . A Psychiatric Progress Note with Therapy Services 10/24/22 at 8:00 PM noted, .seen s/p (status post) Physical interaction with peer, He was seen in his room sitting in his chair, calm, cooperative, easily engaged, during inquiry of that transpired with the incident with his peer, he stated that I was protecting the other resident, one resident was sitting on the chair then went out to use the bathroom, then the resident from 3rd floor came over and sat on the chair, I was telling the guy to got (get) up and he push me 3X (times), and I hit him on his face . The medical record lacked any documented evidence that the facility provided adequate supervision to prevent an altercation between Resident #70 and Resident #169. During a face-to-face interview conducted on 02/28/23 at approximately 1:15 PM, Employee #3 (Director of Nursing) stated that when there is a resident-to-resident physical altercation, staff separate them. 3. Facility staff failed to prevent Resident #131 from repeated episodes of abuse due to inadequate supervision which resulted in physical altercations with Resident #254 and Resident #169. Resident #131 was admitted to the facility on [DATE] with multiple diagnoses that included the following: Dementia, Bipolar Disorder, and Alcohol Abuse. A review of a Facility Reported Incident (FRI) DC00010890 submitted to the State Agency on 07/25/22 documented the following: .At about 4:05 pm report received that [Resident #131] . and [Resident #254] were involved in a physical altercation and [Resident #131] sustain a laceration on the left upper cheek. [Resident #131] was transported to the (Hospital name) . A review of a Facility Reported Incident (FRI) submitted to the state agency on 01/19/23 documented the following: Report received that resident [Resident #131] was involved in a physical altercation with resident [Resident #169] today at 2:50 pm, as he entered the first-floor dining room. Allegedly [Resident #131] was hit by [Resident #169] in the face and a fight ensued . A review of a Facility Reported Incident (FRI) submitted to the state agency on 02/16/23 documented the following: Around 10.49 am this morning, writer heard loud voices and went toward the voices. On approaching the first-floor dining room writer observed [Resident #131] astride [Resident #169] .on the floor near the vending machine towards the rear of dining room. The residents were separated. There was no apparent injury . A review of the medical record revealed the following: [Physician Order] 10/20/21 Monitor for: Specify behaviors yelling, screaming, resisting care, applying soap to his body, anxious document in progress notes every shift . A review of Resident #131's Quarterly Minimum Data Set (MDS) dated [DATE], revealed that the facility staff coded the resident as having a moderate cognitive impairment and no impairment in the upper or lower extremity. The facility staff coded the resident as having no symptoms of psychosis and no behavioral symptoms. [Physician Order] 07/02/22 Monitor for any behaviors. Resident is prescribed a psychotropic medication . [Nurse Practitioner Progress Note] 7/25/2022 at 8:46 PM The nursing staff reported that the patient had a physical Altercation with another in-house patient [Resident #254] and sustained an injury to his left cheek. Plan: The patient was transferred to ER for continuity of care. [Nurses Note] 7/26/2022 at 2:59 PM S/P (status post) ER transfer: Resident returned to unit @1:30pm from hospital transfer. Resident has hematoma of the left eye as well as a laceration above left eye that he received stitches. Resident denies any pain at this time. Residents vitals were 154/90, (p) 74,(r) 22, and (t) 97.6 ax Resident was encouraged to take a shower, but declined. Was able to get resident to change from bloody clothing and perform am care to himself at the bedside. Resident has new orders for Keflex 500mg 2 times a day. Resident did not verbalize any concerns for nurse. [Treatment Administration Record (TAR)] 07/27/22, .Left below eye laceration repaired site: Apply Bacitracin (topical antibacterial) to site every day shift. [Psychological Services Supportive Care progress note] 07/28/22 at 8:21 AM .Met with patient today at the request of the facility after he was assaulted by another resident .Asked patient what happened between he and the other resident. Patient stated I don't remember anything Patient doesn't remembe3r (sp) being taken to the ED for treatment or anything else that happened . [Nursing Progress Note] 01/19/23 at 5:31 PM Report received that at 2.50 pm, resident was involved in a physical interaction with another male resident. [Resident #131] did not sustain any injuries . [Nursing Progress Note] 01/19/23 at 7:39 PM .[Resident #131] was seen to follow up regarding the incident that was reported while in the smoking patio. Mr. [Resident #131] don't have any recollection of any involvement in the smoking patio. Assessment was made, no any bruise or redness on his hand, no sign of any injury noted, he stated that he is fine . [Care Plan] initiated on 1/19/23, Focus :[Resident #131] has a physical aggression with other resident [Resident #169] while in a smoking patio Interventions: Police was called no arrest was made. Psych (psychiatry) consult to evaluate.emphasize to [Resident #131] to refrain from any physical aggression towards other resident while in the smoking patio. [Physicians Order] 02/01/23 Hourly check to know residents where (sp) about due to noncompliance with wearing wander guard or keeping it in place post placement every shift. [Treatment Administration Record] 02/01/23- 02/18/23, Hourly check to know residents where about due to non-compliance with wearing wander guard or keeping it in place post placement Review of the (Treatment Administration Record) TAR from 02/01/23 through 02/18/23 shows that the facility staff checked off one time for one of three shifts (Day, Evening, Night). There was no documented evidence in the medical showing that staff monitored Resident #131's hourly where abouts on or off the unit. [Nursing Progress Note] 02/16/23 at 12:32 PM Around 10.49 am this morning, writer heard loud voices and went towards the voices. On approaching the first floor dining room, writer observed Mr. [Resident #131] on the floor near the vending machine towards the rear of the dining room, astride Mr. [Resident #169]. The residents were separated. There was no apparent injury . [Care Plan] initiated on 02/16/23, Focus: [Resident #131] had a resident to resident interaction with [Resident #169] while in the first dining room Interventions: Emphasize to [Resident #131] to stay away from [Resident #169], Encourage [Resident #131] to report issue and concern to staff Encourage to refrain from being aggressive towards other residents and report any disagreement he has with other residents to staff . [Incident Note] 02/18/23 at 12:37 AM .IDT (interdisciplinary team) had a meeting regarding Mr. [Resident #131] interaction with [Resident #169] 2/16/23 .it was concluded that the root cause is due to poor impulse control and h/o (history of) of aggression. Following intervention in place: Encourage to refrain from being aggressive towards other resident and report any disagreement he has with other resident to staff. Psych (Psychiatry) consult for evaluation. Encourage {Resident #131] to stay away from [Resident #169]. Police was called no arrest was made. Nursing staff will continue to monitor . The facility staff provided the Surveyor with a document dated 2/23/23 titled Smoking Monitors which was reviewed and it stated When these residents are on the smoking patio or waiting to enter the smoking patio, please monitor them to ensure they do not interact negatively with other residents: [Resident #169] [Resident #131] .(other residents names were listed and the total number was seven (7) residents named on the list. Resident #131's medical record lacked documented evidence that the facility staff provided adequate supervision to prevent Resident #131's multiple resident to resident altercations. During a face-to-face interview conducted on 02/28/23 at 12:55 PM, Employee #18 (Unit Manager 3 South) stated that Resident #131 started fighting with Resident #169 after he asked him for a puff of his cigarette in the designated smoking area. After the incident when questioning Resident #131 about the physical altercation that occurred Resident #131 had no memory of it. During a face-to-face interview conducted on 02/28/23 at 2:11 PM, Employee #40 (Smoke Monitor) stated that the altercation started outside after [Resident #169] asked [Resident #131] for a puff of his cigarette then more words were exchanged, and the residents started to fight. 45104 4. Facility staff failed to prevent the non-consensual contact of one resident (Resident #146) towards another resident (Resident #163). A. Review of Resident #163's medical record revealed the Resident was admitted to the facility on [DATE] with diagnoses including: Cerebrovascular Accident, Hemiplegia, Type 2 Diabetes Mellitus, Depression, and Anxiety. A Care Plan dated 06/06/22 revealed: Focus: [Resident #163] has been accused of alleged sexual abuse (accuser). Goal: [Resident #163] will not be involved in alleged sexual abuse through the next review date x 90 days. Interventions: Hourly monitoring till seen by psych .[Resident #163] moved from 307A to 201B .Psych consult due to alleged abuse. Resident #163's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] documenting a Brief Interview for Mental Status (BIMS) summary score of 15, indicating that the Resident had intact cognition. In addition, the MDS assessment noted that the Resident had lower extremity impairment on one side, used a wheelchair for mobility, and required supervision (oversight, encouragement, and cueing), by facility staff for locomotion on and off the unit. B. A review of Resident #146's medical record revealed that the Resident was admitted to the facility on [DATE] with diagnoses including: Schizoaffective Disorder, Alcohol Abuse, Anxiety Disorder Unspecified, and Dementia. A Care Plan dated 09/17/18 documented: Focus: Resident have (has) a behavior of scratching /touching [pronoun] private area in public r/t (related to) impaired cognition Goal: Resident #146 will be redirected and reoriented .Interventions: Anticipate and meet [Resident #163] 's needs. If reasonable, discuss behavior. Explain /reinforce why (the) behavior is inappropriate .Provide a program of activities that is of interest .Psych consult initiated for indecent exposure A Psychiatric Progress Note dated 09/08/22 at 12:30 PM documented: .staff reported that [Resident] (had) been exposing [self] inappropriately to .peers .Counseling was given, discussed consequences if [pronoun] continues to act inappropriately . Treatment Plan Recommendations: .Continue with behavioral monitoring. Review of the Resident's medical record revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE], which documented a Brief Interview for Mental Status (BIMS) summary score of 03, indicating that the Resident had severely impaired cognition. In addition, the MDS assessment noted that the Resident showed wandering behavior, physical behaviors (e.g., scratching, grabbing, abusing others sexually), and verbal behaviors towards others (e.g., threatening others, cursing at others). The MDS also showed that the Resident could ambulate without staff assistance or the use of an assistive device, and was not on antipsychotic medications. A Physician's Order dated 01/19/23 at 9:05 PM directed: Hourly monitoring due to resident's exhibiting indecent sexual behavior every shift. Discontinued 02/21/23 at 11:38 PM. A Psychiatric Progress Note dated 01/23/23 at 12:00 PM documented: .requested to assess (the) patient for 1:1 placement and for possible discontinuation .Stated, 'I did not do anything to anybody' . Treatment Plan Recommendations: .D/V (direct vision) 1:1 line of sight. Start closed observation for behavior, Supportive therapy provided, Continue with behavioral monitoring, F/U (follow-up) as needed Review of a Facility Reported Incident (FRI) (DC00011688) dated 02/21/23 at 9:29 PM documented, At about 9 PM on 02/21/23 [Resident #163] came and reported to this writer that [Resident #146] touch(ed) [pronoun] on [pronoun] chest while on the first-floor dining (sp.) (dining) room and [pronoun] does not like that. There was no injury reported or noted on [Resident #163]. (The) Investigation is in progress . A Physician's Order dated 02/21/23 at 9:38 PM directed: 1:1 monitoring due to resident's exhibiting indecent sexual behavior every shift. A Psychiatric Progress Note dated 02/22/23 at 10:00 AM documented: .asked to evaluation (evaluate) patient for exhibiting high libido by exposing [self ]to female peers .Denied allegation and stated, 'I don't know what you are talking about .Collateral information received from staff, staff report patient exposing [self] to women peers .Chart and medication reviewed . A Care Plan revised on 02/24/23 documented: Focus: 02/20/23 [Resident #163] exposed [pronoun] private part in public - Inappropriate sexual behavior/inappropriate sexual touching; Goal: Resident #163 will not expose [pronoun] private part in public area; Interventions: .Redirect resident whenever [pronoun] is scratching /touching [pronoun] private area in public . Review of a summary update to the FRI (DC00011688) submitted on 02/26/23 at 8:04 PM documented, .[Resident #163] reported that [Resident #146] touched [pronoun] chest without [pronoun] consent while they were in the first-floor dining room .full assessment was completed .[Resident #163] had no evidence of injury .denied pain or any additional concern .[Resident #146] was interviewed by the clinical manager. When [pronoun] was asked about what occurred [pronoun] stated, 'I don't know. What are you talking about?' .According to witness statements, [Resident #146] touched [Resident #163] 's shoulder and said, Excuse me, then asked [pronoun] for a cigarette.[Resident #163] was not seen touching [Resident 163] 's chest. Based on a full investigation and review of witness statements, the facility was not able to substantiate the alleged sexual assault .provider for both residents was made aware . Metropolitan Police were informed .no arrests and no charges filed . [Resident #163 was encouraged to stay away from [Resident #146]. A 02/27/23 at 10:AM [Psychiatric Progress Note] documented: .asked to evaluation (evaluate) patient for exhibiting high libido and by touching [pronoun] female peer inappropriately . Denied allegation and stated, 'You all are lying on me.' .was counseled but patient not receptive to counseling. Collateral information received from staff, report patient exposing [self] to peers. Review of a Nurses Note on 02/27/23 at 5:30 PM documented: Investigation was reviewed again due to the need for clarification of statements. Based on clarification of statements the allegation was substantiated. Resident will be seen by Psych for appropriate interventions .resident is currently on 1:1 monitoring. Team will assign male staff as much as possible. Continue POC (plan of care). Review of an addendum to the Facility Reported Incident (FRI) (DC00011688), submitted on 02/28/23 at 9:41 PM documented: ' .After further investigation, the facility substantiates the resident to resident alleged sexual assault reported by [Resident #163] at 9 PM on February 21, 2023. An eyewitness saw [Resident #146] touch [Resident #163] 's chest just before [pronoun] touched [pronoun] shoulder and asked[pronoun] for a cigarette .Staff will continue to redirect [Resident 146] . will remain on constant monitoring until further notice. During a face-to-face interview on 02/23/23 at 04:54 PM, Resident #163, stated that We were in the cafeteria. I was in my wheelchair, and Resident #146 was walking past me. The Certified Nurse's Aide (CNA), walking with Resident #146 was not paying attention; the CNA turned away from Resident #146 and was talking to another resident. As we were passing each other, Resident #146 said, 'Hey don't I know you? Come here, and [pronoun] reached down and touched my chest. They (the facility) called the police and asked me questions, but they do nothing about this resident. This was not the first time [pronoun] touched me. Another time when we were passing each other in the hallway, the Resident said to me, 'Come to my room,, let's go .' After that I was moved to the first floor. A time before that when I was on the third floor, another resident said that while I was asleep, [pronoun] saw the Resident masturbating outside the doorway in front of my room. The facility knew about the Resident's behavior because [pronoun] was asking everyone [other residents] to perform an oral sex act. Resident #163 could not recall the specific dates that the other two incidences with Resident #146 occurred. During a face-to-face interview on 02/27/23 at approximately 11:30 AM when asked about the incident where [pronoun] touched Resident #146's chest, Resident #163 stated, 'I would like to do that, but didn't know anything about that incident.' During a face-to-face interview on 02/27/23 at approximately 11:30 AM, Employee #20 (CNA/ 1:1 Monitor assigned to Resident #163] from 02/25, 02/26, and 02/27/23, stated the for the past three days, the Resident kept asking the Employee to get [pronoun] a woman. During a telephone interview on 03/10/23, Employee #21 (CNA/1:1 Monitor for Resident #146 on 02/21/23) stated that [pronoun] was walking shoulder to shoulder with Resident #146 in the first-floor dining room. As Resident #146 was walking past other residents, he was asking for a cigarette. When Resident #146 walked past Resident #163, [pronoun] asked [Resident #163] for a cigarette. Resident #163 said, 'No. and [Resident #146] touched [Resident # 163] on the shoulder. Resident #146 never touched Resident #163's breast. When asked if the facility offered the CNA any formal training on 1:1 monitoring of residents, the CNA responded, I never received specific training on 1:1 monitoring from the facility. I had been a 1:1 monitor for other residents in the facility but had never been assigned to Resident # 146 before the day of the incident. I had seen the CNA assigned to Resident #163 the shift before me, walking around the facility with the Resident, so I did what I had seen that CNA do. Review of this evidence showed that facility staff had knowledge and documentation of Resident #146's sexual behaviors towards other residents in the facility before the incident on 02/21/23 with Resident #164. Cross Reference 22B DCMR sect. 3269.1 (l)

Based on record review, resident and staff interview for one (1) of 75 sampled residents, facility staff failed to consistently monitor Resident #274 with sexually aggressive behavior from inappropriately touching female residents. Findings included . Resident #274 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set, dated dated dated [DATE], showed Resident #274 had a Brief Interview for Mental Status (BIMS) score of 13 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 Activities of Daily Living (Functional Status), the resident had no impairment of his upper extremities and used a wheelchair for mobility. Review of Resident #274's record showed a Social Worker note dated, 9/25/2019 at 15:00, Social worker was made aware by nursing that a CNA observed (Resident #274) in a female resident's room with his hand on the female resident private area. At 9:26 AM SW (social worker and Assist Director of Nursing) met with resident to interview him regarding the report from the CNA. During the interview, resident stated, 'I went to the room, nothing happened, I saw she had no draws, I looked but I did't touch her. I know it was wrong going in there and I came out of the room by myself.' Nursing called the police . A review of a care plan initiated 9/26/19 showed Resident #274 was placed on 1:1 monitoring s/p (status [REDACTED]. The 1:1 monitoring was discontinued on 10/1/19. A review of PsychoGeriatric Services, LLC Late entry note for 10/1/19 generated on 10/2/19 showed Chief complaint: Patient seen to evaluate mental status and adjust medications for behavioral disturbance. Chief Complaint: C/O (Complaint of ) of sexual abuse . he was evaluated d/t (due to) report of inappropriate sexual conduct with another female resident. Patient initially denied entering into the patient's room or touched her vaginal, Though after cues was able to answer the question admitting the claim and did not volunteer any further information. It appears that this patient has engaged in this type of behavior in the past. Noted that he was doing well while on [MEDICATION NAME] and [MEDICATION NAME] but both were discontinued apprentice and not sure why . Chart reviewed, no report of agitation or aggression. Patient was counseled and he verbalized understanding. Currently on 1:1 . for safety per facility protocol. Diagnosis: [REDACTED].Major Neurocognitive DisorderUnspecified, without behavioral disturbance - F03.90. Treatment plan/recommendations Plan: Supportive therapy provided. Reviewed SE (side effects) and Risk/ Benefits analysis, Psychiatric team will monitor mood and behavior, Patient encouraged to participate in activities on the unit. Will d/c (discontinue) 1:1 . Start [MEDICATION NAME] 10mg qd (every day) for mood disorder. Nursing staff to maintain close monitoring of patient every shift, and redirect promptly if necessary. SW (Social Worker) note dated 12/19/2019 at 10:02 AM showed, SW met with met with resident at 8:39 AM today s/p alleged inappropriate touching of female resident on 12/18/2019. Upon interview resident stated, I stuck my hand in her pants. I made a mistake, the police told me I will go to jail for doing that. SW counseled resident re the behavior and he expressed understanding. Resident is currently on 1:1 montioring . A review of another care plan initiated 12/18/19 showed Resident #274 was placed on 1:1 monitoring s/p (status [REDACTED]. A face-to-face interview was conducted with Resident #274 on 2/12/20 at approximately 3:00 PM concerning him inappropriately touching female residents' vaginal area. The Resident responded, Yes I want to touch the P____y . The resident was asked where were staff when this happened? The resident responded, I don't know. Transition Healthcare Hourly Resident Monitoring Log showed the following: 9/26/19 to 9/30/19 - showed continuous monitoring of Resident's behavior was checked at the allotted space. 10/1/19 - showed 1:1 started at midnight and discontinued at 8:00 AM. 12/18/19 to 2/14/20 - showed 1:1 started at 12/18/19 4:00 PM and was continuous through this time period. A face-to-face interview was conducted on 2/13/20 at approximately 4:14 PM with Employee #8 concerning the Psych Recommendation on 10/2/20 for Nursing staff to maintain close monitoring of patient every shift, and redirect promptly if necessary. Employee #8 stated, The resident was on 1:1 for a month and that was discontinued on 10/2/19. Prior to the incident on 12/18/19, the resident was being watched by staff and redirected when necessary. There was no monitoring log presented for the Resident's close monitoring from 10/2/19 to 12/17/19. There was no documented evidence to show that facility staff proteceted Resident #233 from being touched in a sexual manner by Resident #274. Resident #274 was not monitored every shift from 10/2/19 to 12/18/19 to prevent him from further inappropriately touching of female resident's vaginal area. On February 13, 2020, approximately at 4:14 PM, Employee #8 acknowledged the findings.

Based on record review and interviews for five (5) of 75 sampled residents, the facility's staff failed to: (1) ensure 1 to 1 monitoring (supervision) was provided for one resident; (2) ensure two (2) residents, who were asssessed as fall risks, recieved adequate supervision; and (3) supervise two (2) residents when placing them in a ride share car (Uber). for two (2) of 75 sampled residents (Residents' #56, #187, #226, #235, and #305). Findings included . (1) The facility's staff failed to ensure Resident #235 recieved 1 to 1 monitoring (supervision), as perscibed. Review of Resident # 235's current medical record on 02/19/20, starting at 1:00 PM, showed that the resident was admitted on [DATE] with multiple diagnoses, including Alteration in Neurological Status related to Closed head Injury, [MEDICAL CONDITION], Muscle Weakness, and Adjustment Disorder with Mixed Anxiety and Depressed Mood. Continued review of the record revealed a physician order [REDACTED]. Further review of Resident # 235's medical record revealed a nursing note dated 01/27/20 that documented, At about 6:05 PM, Resident was noted standing up in the lounge .bleeding from .left eyebrow measuring 0.5cm (centimeter) X 0.5 cm. Resident stated .I was making a move forward when I fell and hit my left eye. The nursing note also documented that the resident was transferred by 911 to the nearest emergency room for further evaluation on that same day at 7:18 PM. However, the nursing note lacked documented evidence that the staff was provided 1:1 monitoring for safety prior to Resident # 235's fall on 01/27/20. Further review of the medical record showed a discharge instruction from a local hospital dated 01/27/20 that documented the resident was seen for Facial laceration (and) Fall. The discharge instructions indicated that the resident's laceration was at the left lateral near temple. Continued review of the discharge instructions revealed that Resident # 235's wound was closed with 4 sutures. Review of the Care Plan dated 12/24/19 lacked documented evidence of the staff's responsibility when providing 1:1 monitoring for the safety of Resident #235. During an interview on 02/19/20 at 3:00 PM, Employee #2 (DON) and Employee # 7 (Unit Manager) acknowledged the finding. Employee #2 then stated that Employee #18 Cetified Nursing Assistant (CNA) left the resident without waiting for her relief. When asked if Employee #18 received training on 1:1 monitoring for safety, Employee #2 and Employee #7 stated, Yes However, the facility had no documented evidence of Employee # 18's training or competency on 1:1 monitoring for safety. Further interview with Employee #2 and Employee #7 revealed that the facility did not have a policy on 1:1 Monitoring for Safety. The facility's staff failed to provide 1 to 1 monitoring (supervision)for Resident #235 on 01/27/20. (2). The facility staff failed to ensure Resident #56 and Resident #305, who were asssessed as fall risk(s), recieved adequate supervision. A. Resident #56 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of Resident's #56's medical record showed that on 02/07/20 at 9: 00 AM, the resident was found in front of the nursing station lying face down bedside her wheelchair. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE], showed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) with a score of 13 which indicated that the resident had moderate cognitive impairment. Section G (Functional Status) resident is coded as 3 extensive assistance with two (2) persons physical assist for bed mobility and transfer and coded 7 activity occurred only once or twice for locomotion on the unit and locomotion off the unit. Section G 0400 Functional Limitation in Range of motion code 0 indicates No impairment. Section J I700 Fall History on Admission/entry was coded as0 to indicate that the resident had no fall 2 - 6 months prior to his admission to the facility. Review of the Care Plan initiated on 12/01/16 showed Resident at risk for falling r/t (related to) dx (diagnoses) of Catatonia and Epileptic [MEDICAL CONDITION] Disorder. However, the Care Plan lacked documented evidence that the staff was to monitor Resident #56 while in her wheelchair. Continued review of Resident #56's medical record revealed a nursing note dated 02/07/20 at 13:42 that showed Resident was noted lying face down by her wheelchair in front of the nursing station. On assessment resident was noted with a swelling to the right frontal part of head active ROM (range of motion) to both upper and lower extremities done, resident obeys commands, and respond to question spontaneously. LOC (level of conciousness) was within normal, alert verbal responsive. neuro check initiated, ice pack applied to swelling on the frontal part of the head (doctor name) . gave order to transfer resident to hospital ER (emergency room ) for evaluation of swelling to the head post fall . During a face to face interview on 2/13/20 at 2:55 PM, Employee #21 stated, Resident was at the nursing station waiting to be picked up for an appointment to the urologist doctor, I placed her there and then went to attend to another resident. During a face-to-face interview on 02/13/20 at 1:44 PM, Employee #8, Unit Manager acknowledged the findings and stated, No one witnessed the resident's fall. The staff assigned to the resident left the resident at the nursing station and went to attend to another resident. The facility's staff failed to supervise Resident #56 on 02/07/20 while she was sitting in her wheelchair at the nursing station. B. Resident #305 was admitted to the facility on [DATE], with several [DIAGNOSES REDACTED]. Review of Resident #305's medical records revealed a nursing note dated 02/08/20 at 9: 00 AM that showed The resident was found on the floor, beside his bed and sitting on his buttocks Review of Resident #305's Quarterly Minimum Data Set ((MDS) dated [DATE] showed Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) with a score of 13 which indicates the resident had moderate cognitive impairment. Section G (Functional Status) resident is coded as 3 extensive assistance with one (1) person physical assist for bed mobility, transfer, locomotion on the unit, and is coded 1 supervision, oversight, encouragement or cueing for locomotion off the unit. Section G 0400 Functional Limitation in Range of motion code 0 indicates No impairment. Section J I700 Fall History on Admission/entry was coded as0 to indicate that the resident had no fall 2 - 6 months prior to his admission to the facility. Review of the Care Plan initiated on 01/20/15 showed Resident at risk for falls r/t (related) gait/balance problems, non-adherence to calling for assistance. The Care Plan lacked documented evidence how staff supervise resident while he was in his room unattended. Continued review of Resident #305's medical record showed a nursing note dated 2/8/20 at 21:20 that showed, Around 3:10 PM resident was noted sitting on his buttock on floor. Beside his bed in his room. The resident stated he was trying to sit in his w/c (wheelchair). Upon assessment .denied hitting his head. No bruise or injury noted this time. Neuro check initiated. The resident was educated to use the call light for assistance. During a face-to-face on 2/18/20 at 12:24 PM, Employee #9, Unit Manager, acknowledged the finding. Employee #9 then stated Resident has consistent falls. He is non-adherent to the education staff gives him. We ask him to call for help, but he still tries to walk and transfer by himself. The facility's staff failed to provide supervision for Resident #305. (3). The facility's staff failed to supervise Resident #187 and Resident #226 after placing them in a ride share car (Uber). A. Review of Resident #187's medical record showed that she was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], showed Section C (Cognition Patterns) C1000 Cognitive Skills for daily decision making was scored as 15 which indicated that the resident was cognitively intact. Under Section G0300 the resident was coded as not steady, but able to stabilize without human assistance, and requires supervision with transfers, locomotion off the unit with one person physical assistance. During a face-to-face interview with Resident #187, on 02/10/20 at approximately 11:00 AM, she stated, I went out with another resident, far out in Maryland to look at an Assisted Living Facility about 3-4 weeks ago. I only went because I was told that if I didn't pick a place I would be discharged to a shelter. Resident #187 then said, I chose not to rent a room at the Assisted Living facility because my [MEDICAL TREATMENT] center is far from the facility, and I have limited income. B. Review of Resident # 226's medical record showed that he was admitted to the facility on [DATE], with several [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE], showed Section C (Cognition Patterns) C1000 Cognitive skills for daily decision making wAS recorded as 13, which indicated that the resident was cognitively intact. Under Section G the resident was coded as requiring supervision to transfers, locomotion off the unit with one person physical assistance, not steady, but able to stabilize without human assistance; Additionally, the resident was coded as having impairment on one side of his upper extremities and using a wheel chair. Through observation on 02/19/20 at 5:35 PM, the resident was observed using a rollator walker to assisst with ambulation. During a face-to-face interview on 02/19/20 at 5:35 PM, Resident #226 explained that on 01/24/20 (Friday), Employee #29, Social Worker, called an Uber to drive him along with another resident (Resident #187) to look at some rooms that were available for rent in Clinton, Maryland, approximately 15 miles away. Continued interview the resident stated, It felt scary for me to be in a car and have no idea where I was going. The resident then stated that the Uber driver dropped him and other resident (Resident #187) off in front of a private home where he met a male (the renter) and a female. Further interview with Resident #226, revealed that the home had available rooms for rent upstairs and downstairs (basement). The resident stated, I was unable to observe the rooms upstairs because I could not go up the steps with my walker and the stairs did not have (hand) rails. Continued interview with Resident #226 revealed that when he made the renter aware he was unable to safely navigate the stairs, the renter told him to go outside to the back of the house, so that he could access the basement from an outside door. The resident indicated that he refused to go to the back of the house because he was not interested in moving so far away from DC. Resident #226 then said, I called the nursing home and informed the social worker (Employee #29) that I did not like the room and needed someone to pick us up. During a face to face interview on 02/19/20 at 5:30 PM, Employee #29, Social Worker, acknowledged the finding. Employee #29 then stated The two residents (Residents #187 and #226) went together in an Uber to Clinton, Maryland. We (the facility) paid for the Uber. It was early in the day. Employee #29 was asked, is this your practice? She replied, I didn't think this was an issue because the gentlemen that owns the Assisted Living is familiar with us (the facility). During a face-to-face interview on 02/19/20 at 5:32 PM, Employee #1, Adminstrator, stated We have a transportation system that has 10 escorts to take residents back and forth to appointments. The facility's staff failed to provide adequate supervision to Residents' #187 and #226 when they sent them without a facility escort to visit an Assisted Living facility in Clinton Maryland, approximately 15 miles away from the nursing home. Through interview with one resident he stated, It felt scary for me to be in a car and have no idea where I was going. and once the resident entered the Assissted Living facility, they did not have hand rails to aid in the resident's safe navigation of the stairs within the home.

Based on review of clinical records, facility documentation, facility policy, residents and staff interviews, it was determined that the facility failed to identify and conduct thorough investigations of resident-to-resident altercations as a potential for abuse; the facility failed to implement measures to protect each resident involved in the incidents; and failed to substantiate or un-substantiate whether the residents were physically or verbally abused for 13 of 87 sampled residents (Residents' #10, #24, #32, #62, #63 #89, 103, #104, #151, #159, 164, #235 and #297). Based on the facility's failures, the Administrator was informed that the facility was in Immediate Jeopardy (IJ)-L was identified at 42 CFR§ 483.10 Abuse, Neglect, and Exploitation on (MONTH) 11, (YEAR) at 6:35 PM. The findings included: On (MONTH) 11, (YEAR), at 6.35 PM an Immediate Jeopardy (IJ)-L was identified at 42 CFR§ 483.10 Abuse, Neglect, and Exploitation. On (MONTH) 11, (YEAR) at 7:05 PM, the facility's Administrator provided a letter to the State Agency Survey team documenting the corrective action plan, which included investigations of previously reported incidents involving Residents' # 10, #24, #32, #89, #104, #151, #159, #235 and #297 for possible abuse in (MONTH) and (MONTH) (YEAR). The incidents will be reviewed and thoroughly completed reflecting root cause analysis and appropriate plans to prevent recurrence. Resident # 24 and Resident #104 were placed on one-to-one. All incidents related to resident-to-resident altercations and allegations of abuse that have been reported to the Department of Health in the last 30 days will be review thoroughly, investigated, documented appropriately, presented to the Interdisciplinary Team for root-cause analysis, and finalized with the results of the investigation including conclusions from the process, how resident(s) involved will be protected from future incidents, and appropriate update to resident care plans. The facility's Abuse Policy was updated and submitted to the survey team on (MONTH) 10, (YEAR). All incidents occurring within the facility will be reviewed, analyzed, and completed according to the Incident Reporting and Abuse policies. Department Heads, IDT (interdisciplinary team) Members and nursing staff will be in-serviced on this updated policy by 12/14/18. The Nursing Quality Improvement Committee will maintain a log of the review of the incidents to identify trends and patterns of care issues and report their findings to the Director of Nurses. The Director of Nurses will review the log and present his findings with any action plans for Improvement to the Quality Assurance and Performance Committee . The IJ was abated after the team verified that the plan of correction was in place on (MONTH) 21, (YEAR), at 3:25 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to an F. Facility Policy Policy Title: OPS-346 Abuse, Neglect, Mistreatment, Exploitation, and Misappropriation of Resident Property Revised 10/27/17 stipulates, A. This facility upholds resident rights to be free and strictly prohibits and prevents verbal, sexual, physical, and mental abuse of residents . B. Residents shall not be subject to abuse by anyone including but not limited to facility staff, other residents . C. It is the policy of the facility to immediately report and thoroughly investigate all allegations of mistreatment, neglect, abuse, misappropriation of resident's property or any injury of unknown origin. Definition of Abuse: 1.Abuse means the willful infliction of injury, measurable unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being . 4. Physical abuse includes hitting, slapping, pinching, kicking, etc. It also includes controlling behavior through corporal punishment. Identification: A. Facility staff will be trained to report any oral or written reports of alleged neglect, abuse, mistreatment, and misappropriation of resident's property. Facility staff must also report injuries of unknown etiology. Investigation: A. The administrator of designee person will report alleged incident immediately to the regulatory agency of that Facilities respective jurisdiction. B.A thorough investigation will be initiated immediately for all alleged incidents of abuse involving staff members, residents, family and/or visitors who have potential knowledge of the incident or its circumstances .D. The Administrator/designee will make all reasonable efforts to thoroughly investigate and address all alleged reports, concern and grievances presented to them, and prevent further potential abuse, neglect .while the investigation is in process 2. Upon receiving reports of physical or sexual abuse, the supervising nurse shall immediately examine the resident .3. The supervisor or charge nurse must report the incident to the Administrator, and Director of Nursing Services and/or Social Worker immediately. 5. Written statements from all staff present during and/or involved in the incident will be submitted to the nursing supervisor . Resident-to-Resident Interaction If a resident is observed being aggressive or exhibiting any form of verbal, physical, or sexual abuse behavior toward another resident, immediate action will be taken to stop alleged abuse and remove the resident from danger. LPN or RN in charge will assess the residents for injury and record findings of the examination. In the event, upon investigation, it is determined that the incident is the result of (inappropriate behavior) from a facility resident, the resident's behavior will be discussed with the resident's family/responsible party, attending physician, and other members of the health care team. Alternate measures to reduce inappropriate behavior such as counseling, medication, or psychiatric evaluations the will be followed as recommended. Note: It is the responsibility of the facility to report such incidents and it is the responsibility of the local and state agencies to determine if actual abuse, neglect or mistreatment of [REDACTED]. Protection of the Resident A. The resident will receive measures to ensure his or her immediate safely .C. Means of providing protection include, but are not limited to: Move resident to another room or unit. Provide one to one monitoring as appropriate. Suspension of staff members as indicated pending investigation .monitor of the resident's physical environment . The following are examples of residents involved in a physical altercation(s) documented by the facility: 1. Resident #89 slapped Resident #10 A review of the Facility Reported Incident (FRI) on 12/4/2018, at 11:00 AM showed: At 2:40 PM, Resident #10 was sitting in the hallway in front of 3N nurses station, Resident #89 was passing by Resident #10 grabbed her hand and refused to let go, so Resident #89 slapped her. There were no investigation statements present with FRI, the resident's care plans were not updated to include interventions regarding this incident, the resident's behaviors and not care planned for abuse. A review of Resident # 89's Quarterly MDS (Minimum Data Set) dated 9/25/18 showed the resident has [DIAGNOSES REDACTED]. Under Section C (Cognitive Patterns) the resident's Brief Interview for Mental Status was 15 indicating the resident is cognitively intact. Under Section E0200 (Behavioral Symptom Presence and Frequency the resident had verbal behavior symptoms directed towards others ( e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual, acts disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming disruptive sounds). Under Section G (Functional Status), the resident required supervision and set up help (no supervision to go off unit). A review of Resident # 10's Quarterly MDS dated [DATE] showed the resident has [DIAGNOSES REDACTED]. Under Section C (Cognitive Patterns) the resident's Brief Interview for Mental Status was 99 indicating resident was unable to complete assessment. The resident had no behavioral symptom present under Section E0200. Under section G (Functional Status) the resident was coded for extensive assistance with one to two-person assistance required for all Activities of Daily Living and required supervision for locomotion on unit -oversight, encouragement or cueing one person assist. There was no evidence facility appropriately intervened to prevent future episodes of abuse occurring. 2. Resident #24 punched Resident #151 in her chest. Resident #24 was admitted to the facility on (MONTH) 04, 2010, with [DIAGNOSES REDACTED]. A review of Resident #24's Annual Minimum Data Set, dated dated dated (MONTH) 1, (YEAR), under Section C (Cognitive Patterns) showed a Brief Interview for Mental Status Score of 14 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 Activities of Daily Living (Functional Status) the resident is coded as needing no assistance for bed mobility or transfer. She needs physical assistance from one person in the form of supervision/oversight, encouragement or cueing for walking in her room, supervision in toilet use, limited assistance in personal hygiene and extensive assistance in dressing. She eats independently but requires physical help in bathing and ambulates with a walker. Under Section E100 Behavior (Potential behaviors of [MEDICAL CONDITION]) the resident is coded as displaying verbal behavioral symptoms (threatening, screaming, cursing at others) to others and also displaying disruptive behaviors. Review of Resident #24's care plans failed to reveal any evidence of care plans with goals and interventions to protect the resident from resident-to-resident abuse and deter future altercations. Resident #151 was admitted to the facility on (MONTH) 7, 2012 with [DIAGNOSES REDACTED]. A review of Resident #151's Annual Minimum Data Set (MDS) dated (MONTH) 20, (YEAR) showed a Brief Interview for Mental Status (BIMS) score of 15 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 Activities of Daily Living (Functional Status) the resident is coded as needing extensive physical assistance from one (1) person for bed mobility, transfer, walking in room, dressing, personal hygiene and limited assistance for toilet use. The resident is totally dependent on staff for bathing. She needs setup help for eating but eats independently. She uses a wheelchair and is independent with locomotion on the unit but requires supervision oversight and set up assistance when off the unit. Review of Resident #151's care plans failed to reveal any evidence of care plans with goals and interventions to protect the resident from resident-to-resident abuse and deter future altercations. Review of the facility's incident report showed that on (MONTH) 17, (YEAR), Resident #24 punched Resident #151 (an elderly woman who sits in a wheelchair) in her chest because she did not give her a cigarette. During a face-to-face interview with Resident #151 on (MONTH) 12, (YEAR) at 11:00 AM. The resident explained that the incident was unprovoked. She stated that while she was sitting in her wheelchair in the hallway Resident #24 walked over and said, 'Give me a cigarette.' and when she responded that she did not have a cigarette, Resident #24 struck her in the chest with her fist. A face-to-face interview was also conducted with Employee #4 at approximately 3:00 PM on (MONTH) 12, (YEAR). The employee acknowledged that most of the residents usually have misunderstandings with each other but he never thought of them as abuse because they are usually friendly with each other shortly after the altercations. The facility staff failed to identify the altercation as a form of resident-to-resident abuse. Employee #4 acknowledged the finding. 3. Resident #297 and Resident #24 Resident #297 had a physical altercation with Resident #24 on (MONTH) 02, (YEAR). The Resident #297 grabbed the resident's walker and pushed her to the ground. Resident #297 told the staff that Resident #24 kept following him and asking for cigarettes. Resident #297 was admitted to the facility on (MONTH) 24, 2013, with [DIAGNOSES REDACTED]. A review of Resident #297's Annual Minimum Data Set, dated dated dated (MONTH) 17, (YEAR) showed a Brief Interview for Mental Status score of 13 which is an indication that the resident is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 (Functional Status) the resident is coded as independent for bed mobility, transfer, walking in the room and in the corridor, locomotion on the unit. The resident requires extensive physical assistance from one person for personal hygiene and physical support from one person for bathing. According to the MDS the resident displays aggressive and threatening behavior and screams and curses at others. Review of Resident #297's care plans failed to reveal any evidence of care plans with goals and interventions to protect the safety of all residents and prevent further incidents of verbal and/or physical abuse. On (MONTH) 12, (YEAR) at 3:00 PM, Employee #4 acknowledged that facility staff failed to identify the resident-to-resident incident as an altercation and develop strategies to prevent further episodes. 4. Resident #63 and Resident #164 According to Facility Reported Incident Resident #63 was involved in a verbal altercation with another resident (Resident #164) on (MONTH) 15, (YEAR). One of the two residents called Metropolitan Police. The police arrived at the facility, interviewed both residents and left without filing any charges on either resident. No information was given to the facility. Resident #63 was admitted to the facility on (MONTH) 20, (YEAR) with [DIAGNOSES REDACTED]. A review of Resident #63's Annual Minimum Data Set (MDS) dated (MONTH) 15, (YEAR) showed a Brief Interview for Mental Status score of 13 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 Activities of Daily Living (Functional Status) the resident is coded as independent and not requiring any assistance in performing the following activities of daily living: Bed Mobility, Transfer, Walk in the room and/or corridor, Locomotion off unit, dressing and eating. He does however, require set up help from staff when he uses the toilet and requires extensive physical assistance from one person (providing weight bearing support) during personal hygiene, (bathing, shaving, brushing teeth etc.) Review of Resident #63's care plans showed no evidence that the incident was identified as abuse or the development of plans with goals and interventions to prevent further episodes in the future. A face-to-face interview was conducted with Resident #63 at approximately 2:00 PM on (MONTH) 12, (YEAR). When asked about the incident with the police the resident said he did not want to talk about but added that he has known the Resident (Resident #164) for a long time and Now she is funny. Resident #164 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. A review of Section C400 of the annual Minimum Data Set (MDS) with an admission Assessment Reference Date of (MONTH) 04, (YEAR) showed a Brief Interview for Mental Status (BIMS) score of 14 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 Activities of Daily Living (Functional Status) the resident is coded as requiring extensive assistance in performing the following activities of daily living: Bed Mobility, Transfer, dressing, personal hygiene and toileting; requires supervision and set up for Locomotion and uses a wheelchair, hygiene and toileting and needs physical help and support for bathing. Resident #164 refused to be interviewed by this Surveyor. Review of Resident #164's care plans showed no evidence that the incident was identified as abuse or the development of plans with goals and interventions to prevent further episodes in the future. During a face-to-face interview with Employee #4 at approximately 3:00 PM on (MONTH) 12, (YEAR), the employee stated that the residents have arguments and disagreements one day and get friendly the next day. The employee acknowledged that the facility staff failed to identify the altercation as a form of resident-to-resident abuse. 5.Residents' #62 and #103 According to the facility's report Resident #62 and Resident #103 were involved in a verbal altercation on (MONTH) 10, (YEAR). Both residents were residents were heard yelling and shouting expletives at each other and threatening to fight. Resident #62 was admitted to the facility on (MONTH) 02, 2014 with [DIAGNOSES REDACTED]. A review of Section C400 of Resident #62's annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of (MONTH) 05, (YEAR) showed a BIMS (Brief Interview for Mental Status) score of 15 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0100 Activities of Daily Living (Functional Status) the resident is coded as needing extensive physical from two or more persons for bed mobility. She is totally dependent on two or more staff for transferring. She needs extensive assistance from one staff for dressing, bathing and personal hygiene and is totally dependent on two or more staff for toileting. The resident eats independently and uses a wheelchair. No behavior issues were coded on the MDS. Resident #103 was admitted to the facility on (MONTH) 14, 2011 with [DIAGNOSES REDACTED]. A review of Section C400 of Resident #103's annual MDS (Minimum Data Set) with an ARD (Assessment Reference Date) of (MONTH) 12, (YEAR), showed a BIMS (Brief Interview for Mental Status) score of 15 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0100 Activities of Daily Living (Functional Status) the resident is coded as independent in all areas. He is classified as being unsteady on transferring, turning, walking and getting on and off toilet but stabilizes self without assistance. The resident eats independently and uses a wheelchair. Under Section E Behavioral Symptoms the resident classified as directing symptoms toward self rather than towards others and rummaging. Nursing notes describes the resident as hoarding food and other items. Review of the documentation on the incident report and on the Progress Notes indicated that both residents were in the hallway verbally abusing each other. Upon observation the residents reside in adjacent rooms and both are wheelchair bound. The psychologist and family members were notified but no care plans with goals and approaches were implemented to decrease and/or prevent future episodes. A face-to-face interview was conducted with Employee #4 at approximately 3:00 PM on (MONTH) 12, (YEAR). The employee acknowledged that the facility failed to classify and treat the resident-to-resident altercation as an abuse. 6. Resident #104 Resident# 104 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] on 12/11/18 at 11:00 AM showed Section C (Cognitive Patterns) Brief Interview for Mental status (BIMS) was scored as 13 which indicate cognitively intact. Review of the Resident #104 care plan showed focus: Resident has a behavior problem r/t (related to) cursing, yelling and using profane language on staff and residents; goal Resident#104 will have fewer episodes of refusal x 90 days, will have fewer episodes of disagreement with his roommate during the next 90 days. Interventions include: Anticipate and meet needs, monitor the relationship between resident and his roommate, educate family/caregivers on successful coping and interaction strategies encouragement and active support by family/caregivers when resident use these strategies, explain all procedures to before starting to adjust to changes, intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner, resident was instructed to stay away from the other resident by police officer, offered a room/unit change but he declined, resident verbalized that he will stay away from the other resident. Resident #104 was involved in physical or verbal altercations with the following residents: Resident #159 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] on 12/11/18 showed Section C (Cognitive Patterns) Brief Interview for Mental status (BIMS) was scored as 8 which indicated cognition moderately impaired. Resident #235 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] on 12/11/18 showed Section C (Cognitive Patterns) Brief Interview for Mental status (BIMS) was scored as 99, indicating the interview could not be completed. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set ((MDS) dated [DATE] AM showed Section C (Cognitive Patterns) Brief Interview for Mental status (BIMS) was scored as 13 which indicate cognitively intact. Review of the facilities investigative reports showed Resident #104 was involved in multiple resident-resident altercations to include physical or verbal abusive with Resident# 32, #159 and Resident #235. A review of the facility investigative report dated 10/3/18 showed at about 3:10 PM it was reported by Assistant Director of therapy, that Resident #104 had physical altercation with Resident #235 while they were in the elevator, Resident was asked what happened while they were in the elevator and the resident said I am not allowed to talk to other people, you want to start some s .with me now. Another facility investigative report dated 10/15/18 showed at 1:45 PM, it was reported the Resident# 104 got in to physical altercation with his roommate (Resident# 159), he was on top of him grabbing and hitting him. Resident #104 verbalized being taken by surprise and verbalized they were both using profanity towards each other. Behavior note dated 11/27/18 showed Resident #104 was noted cursing Resident #32 in the hall way, both were screaming, yelling at each other, they were separated and redirected. Review of Resident #235 medical record identified the following the following dates of physical/verbal abuse to residents and staff: Incident note dated 10/3/18, Assistant Director of therapy reports resident was involved in a verbal altercation with Resident# 104, while they were in the elevator. Behavior note dated 10/6/18, Resident refused care and assign Certified Nursing Assistant (CNA) attempted X3, resident was cursing saying f .you go clean yourself. Verbally abusive note dated 10/18/18, Resident was heard yelling and cursing to the CNA, while the CNA was passing the snack, Resident stated f .that food. Verbally abusive noted dated 10/20/18, Resident was sitting in the hallway in front of the nurse's station and heard saying get this stinking s .from here she has to go back to her floor. Resident was redirected and told not to insult other residents and he responded I don't care. A further review of the medical record showed an Interdisciplinary note dated 10/30/18, resident has behavior of noncompliance with medication and behavior of verbally abusive to staff. A review of the care plan failed to show physical/verbal abuse as an area of focus, hence there were no listed goals, approaches or specific interventions to address the resident's physical/verbal behavior toward other residents and staff. There were no investigative statements present with Facility Reported Incidents (FRI's), the resident behaviors were not care planned as abuse. Interview with the Facility's Investigator (Employee #2, Director of Nursing) During a face-to-face-interview on 12/11/18 at 1:45 PM, Employee #2 (the Facility's Abuse Investigator and Director of Nursing Services) who stated, I investigated all incidents as resident-to-resident abuse. I talk to the residents, I am not writing down the conversations, we do not write down the resident's statement, I do no write if the investigation was substantiated or unsubstantiated, the grievance form was not used. Based on record and policy review and staff interview, there is no evidence that after the facility recorded resident-to-resident altercations that a documented thorough investigation was completed related to the potential for abuse. In addition, there is no evidence that staff implemented measures to protect each resident involved in the incident or developed person-centered care plans with specific interventions for residents involved in the incidents of abuse or alleged abuse; and there is no evidence facility staff substantiated or unsubstantiated if residents where physically or verbally abused by other residents. During a face-to-face interview on (MONTH) 11, (YEAR), at 1:45 PM, Employees #1 and #2 acknowledged the findings.

Based on observation, medical record review, resident and staff interviews for three (3) of 90 residents identified as a Dependent Smokers, the facility staff failed to ensure measures were implemented to prevent Resident #319 from keeping in his possession smoking material (cigarettes, lighter) after he was observed smoking in his resident room; and two (2) residents identified as dependent smokers from maintaining smoking materials on their person. The facility staff failed to identify one (1) of 87 residents as an elopement risk, therefore a plan of care was not implemented to help prevent him from eloping. Subsequently, the resident eloped from the facility on (MONTH) 9, (YEAR). Also, the facility staff failed to implement a recommendation from the Behavioral Health Specialist to have one (1) of 87 residents attend psychotherapy to address his behavior (drinking alcohol). Subsequently, the resident was found lying on the floor several times related to intoxication and ultimately sustaining harm (Subarachnoid Hemorrhage, Left Supracondylar Fracture and laceration below left eyebrow). Residents' #319, #26, #63, #53 and #112. Findings included . A. On (MONTH) 10, (YEAR), at 6:01PM an Immediate Jeopardy (IJ)-L was identified at 42 CFR§ 483.25 (d)(1) Accidents -The environment remains as free of accident hazards as is possible; and 483.25 (d)(2) Each resident receives adequate supervision and assistance devices to prevent accidents. On (MONTH) 10, (YEAR) at 6:35 PM, the facility's Administrator provided a letter to the State Agency Survey team documenting the corrective action plan, which included: The family of Resident #319 was contacted and it was enforced that he is not to have either cigarettes or incendiary devices on his person or in his room. They acknowledged understanding. The Smoking Policy was revised as of (MONTH) 21, (YEAR), (to clarify information related to resident's discharge). All smokers are now considered Dependent Smokers and will not be able to carry either tobacco or incendiary devices at any time. All smoking will be supervised as determined by the facility. The Director of Social Workers, and Administration met with each smoker, their responsible party/guardian to inform them of the new policy, and their acknowledgement and sign off was required. Failure to abide by the facility's policy will result in a Notice of Infraction which will allow a 7 day grace period to comply with the Smoking Policy. If a resident continues to be non-compliant, the resident will be issued a 30-day involuntary discharge notice. All safe smoking recommendations will be included in the care plan process. The Smoking Policy will be included in the admissions packet and reviewed with each resident upon admission. The resident will be required to sign the acknowledgement of Smoking Policy document. Information in respect to smoking cessation will be provided to encourage wellbeing. The IJ was removed after the State Agency Survey team verified that the plan of correction was in place and being implemented on (MONTH) 21, (YEAR), at 3:25 PM, the Immediate Jeopardy was removed. Consequently, the State Agency amended the scope and severity of the deficient practice to an G. Smoking Policy effective 11/26/18, stipulates, It is the policy of the Facility to allow Residents the privilege to smoke in a safe manner while restricting smoking to designated areas of the facility grounds, and in compliance with applicable laws. Smoking is prohibited in all enclosed areas of the Facility. The Facility's primary obligation is to provide a safe environment for all residents. Therefore, any resident that does not comply with the facility's smoking rules may be asked to forfeit smoking privileges. If the danger or lack of compliance is serious enough, it may warrant consideration to discharge in accordance with state and federal law. 1.The Resident #319 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated dated (MONTH) 13, (YEAR), showed the resident has a BIMS score of 10 indicating he has moderate cognitive impairment. Section E (Behaviors) showed the resident had no behavioral symptoms, but was coded for wandering. Under Section G (Functional Status), the resident was coded as requiring supervision in bed mobility, transfers, walk-in corridor, dressing and personal hygiene. He had no impairment to his upper and lower extremities and required no mobility devices for ambulation. Review of the medical record showed the following progress noted: October 13, (YEAR) at 22:22 incident note at 9:23 PM showed, The facility's fire alarm came on; it was further traced to room [ROOM NUMBER], where the smoking alarm had triggered. Upon entering the room, nurse could perceive strong cigarette odor and cigarette ashes we noted in the trashcan (flammable receptacle) beside resident. During interview resident denied smoking cigarette resident refused assessment and denied smoking and no obvious injuries noted . Transitional Care Center Capital City Smoking Rules acknowledgement form(s) was signed by the Resident on (MONTH) 13, (YEAR) and (MONTH) 14, (YEAR). Assessments: Smoking assessment- August, 11, (YEAR) -can light his own cigarette, no adaptive equipment needed-does the resident store lighter and cigarette Smoking assessment - (MONTH) 16, (YEAR) - resident caught smoking in room; now not able to light own cigarette and requires supervision- the facility now stores and lights the resident cigarette. Observation and interview with Resident #319 (room [ROOM NUMBER]B) On (MONTH) 10, (YEAR) at approximately 3:20 PM during a tour of 2 North, room [ROOM NUMBER]B, Resident #319 was asked if he still smoked and he said yes. He was asked if he had any cigarettes or lighter with him and he said yes and he pulled out of his coat pocked a pack of Newport 100's and a red lighter. At 3:45 PM on (MONTH) 10, (YEAR), a follow up interview was conducted with the Resident in the presence of Employee #2 (DON). At this time, this surveyor observed Resident #319 in the hallway on 2 North. Employee #2 asked him if he had a lighter and Resident #319 nodded his head and showed Employee #2 a red lighter. When asked by Employee #2 where he got the lighter, Resident #319 said that he bought it for a dollar or two yesterday (Sunday, (MONTH) 9, (YEAR)) when he was out with his niece. When this surveyor asked Resident #319 if he was searched by staff when he returned to the facility he said no. When Employee #2 told Resident #319 that he had signed a letter saying that he should not have a lighter, Resident #319 said that he was not aware that he was not supposed to have a lighter. Resident #319 also denied that he ever smoked in his room. A face-to-face interview was conducted on 12/10/18, at 5:30 PM with the Administrator, Director of Nursing (DON), Assistant Director of Nursing, and the Clinical Manager. During this time, DON stated the resident is challenge and he is non-compliant with the smoking policy. The Clinical Manager, present during the interview stated, the social worker has the lighter; we search him at night. Because he is able to go out and his brother takes him out this is how he gets a new lighter. The Clinical Manager and Director of Nursing were asked based on the resident's care plan, how does the facility ensure the resident does not have smoking materials in his possession? The Clinical Manager stated the resident goes to the smoking area and the attendant lights the cigarettes. The Assistant Director of Nursing stated, we search his room when he goes out of the facility. He does not go out (on leave of absence) by himself. The last time he was out of the building was on (MONTH) 9, (YEAR), with his brother. The facility failed to show evidence of their approach to monitoring the resident for the possession of smoking materials. Review of Resident #319's care plan last revised on (MONTH) 15, (YEAR), showed, Focus- (Resident #319) is a current smoker. (He) was caught smoking in his room over the weekend. He is considered a dependent smoker. Interventions: SW (social worker) has spoken to (Resident #319) about the episode of smoking in his room. He gave me his lighter and I will be calling his guardian .to tell him not to bring him any more lighting material in the facility he will now be considered a dependent smoker .Staff will light (Resident #319's) cigarettes. Review of the Smoker List dated (MONTH) 10, (YEAR), Resident #26 in room [ROOM NUMBER] and Resident #63 in room [ROOM NUMBER]A were identified as Dependent Smokers, Per the Facility's Smoking Rules the Dependent Smoker -requires staff, family/friends or physical support or supervision to smoke safely. (MONTH) need to wear protective safety equipment when necessary. These residents were observed on (MONTH) 10, (YEAR), at approximately 3:30 PM to be in possession of cigarettes and a lighter. Facility staff were not aware that the residents were in possession of these items (cigarettes and lighter). 2.Resident #26 was admitted to the facility on (MONTH) 16, (YEAR), with [DIAGNOSES REDACTED]. A review of Section C400 of the annual Minimum Data Set (MDS) with an Assessment Reference Date of (MONTH) 30, (YEAR), showed a Brief Interview for Mental Status (BIMS) score of 15 which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 Activities of Daily Living (Functional Status) the resident is coded as totally dependent and needing physical assistance from two (2) persons for bed mobility, transfer, toilet use, personal hygiene and bathing. She is able to eat with supervision and support and also manages her motorized wheelchair with supervision and support. During a face-to-face interview with the resident on (MONTH) 10, (YEAR), at approximately 3:30 PM the resident informed this surveyor that she had a lighter and two (2) cigarettes in her possession. Employee #4 retrieved the cigarettes and the lighter from the resident. The resident signed her acknowledgement of the Smoking Policy on (MONTH) 16, (YEAR), (on admission to the facility) and (MONTH) 18, (YEAR). Review of the Smoking assessment dated (MONTH) 19, (YEAR), showed the resident was assess as a dependent smoker r/t (related to) right side weakness/right arm paralysis and according to the assessment the Resident does need the facility (staff) to store the lighter and cigarettes. Review of the care plan showed that the resident was described as a Dependent Smoker. The initiation date on the care plan was (MONTH) 11, (YEAR), and the focus was that the resident as a dependent smoker would not be able to carry either tobacco or incendiary devices at any time. The goal is that the resident will practice safe smoking while in the facility by abiding with the facility's smoking policies. The interventions included the following: that the resident was to hand over all smoking paraphernalia, submit to searches of person and room every shift, will be given the option of attending smoking cessation classes and may be discharged from the facility if she refuses to adhere to the facility's policies. During a face-to-face interview with Employee #4 at approximately 11:00 AM on (MONTH) 12, (YEAR). The employee was asked whether he was aware that the resident had smoking paraphernalia either in her room or on her person. The employee acknowledged that he was unaware that the resident kept smoking paraphernalia in her room and/or her person. Employee #4 also acknowledged at that time that facility staff failed to ensure that Resident #26's environment was free of cigarettes and other incendiary devices. 3. Resident #63 was admitted to the facility on (MONTH) 20, (YEAR), with [DIAGNOSES REDACTED]. A review of Section C400 of the annual Minimum Data Set, dated dated dated (MONTH) 15, (YEAR), showed a Brief Interview for Mental Status score of '13' which is an indication that the resident is cognitively intact and able to make decisions. Under Section G0110 Activities of Daily Living (Functional Status) the resident is coded as independent and not requiring any assistance in performing the following activities of daily living: Bed Mobility, Transfer, Walk in the room and/or corridor, Locomotion off unit, dressing and eating. He does however, require set up help from staff when he uses the toilet and requires extensive physical assistance from one person (providing weight bearing support) during personal hygiene, (bathing, shaving, brushing teeth etc .) During a face-to-face interview with Resident #63 on (MONTH) 10, (YEAR), at approximately 4:00 PM this surveyor asked the resident whether he has cigarettes and/or a lighter. The resident responded yes and explained that he had cigarettes and a lighter; but refused to show the items. Employee #4 (The Manager) entered the room and retrieved six cigarettes and a lighter from the resident. The employee was asked whether the resident was allowed to keep cigarettes and/or incendiary devices. The employee responded No and added that he was not aware that the resident had cigarettes and/or incendiary devices. Review of a care plan for the resident with a documented start date of (MONTH) 23, (YEAR), showed that the resident is identified as a dependent smoker and will not be able to carry either tobacco or incendiary devices at any time. The goal was documented that the resident would practice safe smoking by abiding with the facility's smoking policies; with interventions which included the following: that the resident was to hand over all smoking paraphernalia, submit to searches of person and room every shift, will be given the option of attending smoking cessation classes and may be discharged from the facility if he refuses to adhere to the facility's policies. Employee #4 acknowledged that facility staff failed to ensure that Resident #63's environment was free of cigarettes and other incendiary devices during an interview at 11:00 AM on (MONTH) 12, (YEAR). The resident signed his acknowledgement of the Smoking Policy on (MONTH) 22, (YEAR) (two days after admission to the facility). Review of Smoking assessment dated (MONTH) 11, (YEAR), showed the resident was assessed as a Dependent Smoker r/t (related to) impaired cognition/impulsive behavior/in house; and according to the assessment the Resident does need the facility (staff) to store the lighter and cigarettes. The facility staff failed to assess the effectiveness of the smoking plan implemented for Resident #319 who was noted to be smoking in his room and discarded the ashes in a flammable trash receptacle. Resident #319 was then assessed to be a Dependent Smoker, yet on (MONTH) 10, (YEAR), he was found to have cigarettes and a lighter on his person which is a direct violation of the Facility's smoking rules. In addition, Residents' #26 and#63 who were deemed Dependent Smokers were also found to be in possession of smoking materials on (MONTH) 10, (YEAR). There was no evidence that facility staff provided sufficient supervision to each resident deemed as a Dependent Smoker to ensure they are not in possession of smoking material as resident smoking in the build presents as a potential for harm to the dependent resident who is smoking, other residents, staff and visitors. On (MONTH) 10, (YEAR), at 5:30 PM, during the face-to-face interview with the Administrator, Director of Nursing, Assistant Director of Nursing, and the Clinical Manager acknowledged the findings. B. Facility staff failed to identify Resident #53 as an elopement risk, therefore a plan of care was not implemented to help prevent him from eloping. Subsequently, the resident eloped from the facility on (MONTH) 9, (YEAR). Resident #53 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated dated (MONTH) 6, (YEAR), showed the resident has a BIMS score of 05 indicating he has severely impaired cognition. Section E (Behaviors) showed the resident displayed verbal behavioral symptoms directed towards others and other behavioral symptoms not directed at others and the resident was coded for wandering. Under Section G (Functional Status), the resident was coded as independent in bed mobility, transfers, walk-in corridor, and locomotion on and off the unit. Under Section 0300 (Balance During Transitions and Walking) the resident was coded as not steady, but able to stabilize without staff assistance. Under Section G0400 (Functional Limitation in Range of Motion) the resident had no impairment to his upper and lower extremities and required a cane for ambulation under section G0600 (Mobility Devices). Review of the Elopement/Wandering assessment dated (MONTH) 30, (YEAR), the resident was assessed to have verbalize about wanting to leave the facility. Review of the progress notes showed the following: September 9, (YEAR), at 4:28 AM During routine rounds at 11:15 PM, resident was not found in bed. Evening nurse stated, resident is in the building that he did not signed out on LOA (Leave of Absence). At 12 AM call was made to front desk if resident signed out of the facility, they stated that he didn't sign out as per their records. Then we began a search of the building and he was nowhere to be found. A call was made to the police at around 1:30 AM and was informed that they have the Resident at 7 District. He was brought back to the facility at 2:30 AM (on (MONTH) 10, (YEAR)) by (Name of Police Officer) On assessment , resident received in stable condition, unharmed alert and oriented x 1 to person with intermittent confusion .He is now being monitored closely for elopement risk. According to a physician's orders [REDACTED]. every shift for elopement risk. Review of the care plan initiated on (MONTH) 22, (YEAR), Focus area- .at risk for elopement r/t (related to) confusion and [DIAGNOSES REDACTED]. Do elopement checks every one hour as necessary and document as indicated .monitor Wander Guard q (every) shift . There was no evidence that after facility staff identified the resident as an elopement risk, a plan of care was implemented to help prevent him from eloping. Subsequently, the resident eloped from the facility on (MONTH) 9, (YEAR). During a face-to-face interview on (MONTH) 11, (YEAR), at 11:45 AM with Employees' #2 and #6, they acknowledged the findings. C. Facility staff failed to implement a recommendation from the Behavioral Health Specialist to have Resident #112 attend psychotherapy to address his behavior (drinking alcohol). Subsequently the resident was found lying on the floor several times and ultimately sustaining harm (Subarachnoid Hemorrhage, Left Supracondylar Fracture and laceration below left eyebrow). Resident #112 was readmitted to the facility on (MONTH) 4, (YEAR), with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set, dated dated dated (MONTH) 7, (YEAR), showed the resident has a BIMS of 13 indicating he is cognitively intact. Section E (Behaviors) showed the resident was coded as having verbal behavioral symptoms. Under Section G (Functional Status), the resident was coded as requiring supervision in bed mobility, transfers, walk-in room, dressing, toilet use and personal hygiene. He had no impairment to his upper and lower extremities and required a walker for mobility. Care plan last updated on (MONTH) 21, (YEAR), with a focus area of .has history of [MEDICAL CONDITION] list the following interventions: Document any abuse of substance in resident's chart, educate resident on the importance of not drinking alcohol beverage while medication, labs as ordered, medication as ordered- 2/1/2016. [MEDICAL CONDITION], allow resident to rest, safety and fall precautions maintained, (Behavior Health Specialist Company)-3/10/2017. Re-educate (Resident) about the risk and implications of taking alcohol while connected with his behavior of always being intoxicated and it was explained to him that it could lead to causing harm and injury to himself- initiated 1/1/2018. Care plan last updated (MONTH) 4, (YEAR), with a focus area of .at risk for falls listed the following interventions: a working reachable call light, bed in low position, personal items within reach-2/1/2016. He was advised to stop drinking and consider support service for help - 8/6/2018. Re-emphasized and educate (Resident) about all of his fall is connected with his behavior of being intoxicated and it was explained to him that it could lead to causing harm and injury to himself- initiated 1/1/2018. Review of the Resident's medical record shows the following notes: August 3, (YEAR), at 15:01 (PM) Resident signed out on pass . (MONTH) 3, (YEAR), at 21:46 (PM) Resident returned from LOA (Leave of absence) at 4:15 PM resident was noted verbally abusive to staff and smelling of alcohol .On (MONTH) 4, (YEAR), at 16:50 (PM) resident was found on the floor crying for help in between the two beds, with the face on the floor, the left side of his eyes was noted with hematoma .breath smells of alcohol .(Attending) made aware and said to transfer resident to the nearest ER (emergency room ) . August 5, (YEAR), at 05:09 (AM) Post ER visit .ER Diagnosis: [REDACTED]. Note written by Certified Registered Nurse Practitioner (CRNP) from (Behavioral Health Services Company) on (MONTH) 6, (YEAR), showed, On (MONTH) 4, (YEAR) (Resident #112) had a fall in his room, reportedly was intoxicated with alcohol, he was sent to the ER (emergency room ) . but was brought back same day, no serious injury noted. Resident was re-educated on the negative effects of alcohol, he still resists alcohol treatment program outside the facility . Recommendations/Continue to monitor mood and behavior Supportive care. Resident was formerly on psychotherapy, will recommend he re-start psychotherapy as he had consistently decline drug treatment program. Care Coordination: Discussed with nursing team/nurse mgr (manager). Note written by CRNP from (Behavioral Health Services Company) on (MONTH) 6, (YEAR), showed, Assessment: resident seen, negative effects of alcohol reiterated, .he still resists alcohol treatment program outside the facility . Recommendations/Continue to monitor mood and behavior Supportive Care. He will benefit from psychotherapy. Care Coordination: Discussed with nursing team/nurse mgr (manager). October 6, (YEAR) at 16:29 (PM) Resident observed lying on his back on the floor at hallway nearby room [ROOM NUMBER] door His walker rollator was noted with 3 bottles of vodka in a black plastic bag, one of them almost finished Resident refused assessment .refused no one to touch him .(Attending Physician) was on the unit and he made aware no new order given . November 3, (YEAR), at 11:21 AM Resident was noted to be drunk with strong odor of alcohol smell coming of his mouth on taking over the shift. Resident weak, staggering while walking and stated, this is the effect of the alcohol I drank yesterday night. One bottle of vodka was also found under the pillow, same removed and discarded. Fall and safety precaution maintained . November 4, (YEAR), at 15:56 (PM) At around 2:30 PM, .I found (Resident) lying down on his left side with the left face on the floor. Resident disoriented and talking incoherently. Resident noted with strong smell of alcohol .Upon assessment, resident is disoriented , weak confused, intoxicated with scant bleeding on the left side of the face, laceration on the left eye brow resident observed with right side twitching .Unable to move left hand .(Attending Physician) made aware who gave order to transfer resident to ER for evaluation. November 5, (YEAR), at 07:59 (AM) Resident admitted at (Hospital) with undisclosed dx (diagnosis). November 8, (YEAR), at 22:11(PM) Resident was readmitted to the unit at 4:45 PM with the following [DIAGNOSES REDACTED].laceration below left eye brow with 8 stiches . Note written by CRNP from (Behavioral Health Services Company) on (MONTH) 12, (YEAR), showed, Assessment: Facility request to re-evaluate resident who recently returned from hospital due to alcohol induced fall, with fracture of LF (left) hand .Reportedly resident was intoxicated, lost control and fell with fracture. He claimed he was in pain, and had to drink alcohol to numb his pain . Recommendations/Plan: Health teaching related to consequences of abuse was reiterated .not ready to take responsibility for his actions. He will benefit from psychotherapy. Continue to provide health teaching .Care Coordination: Discussed with nursing team/nurse mgr (manager). Review of the record showed that on (MONTH) 3, (YEAR), the resident stained a fall with injury, on (MONTH) 6, (YEAR), the resident sustained [REDACTED]. Although the resident was seen by a Behavioral Health Specialist, there is no evidence that the recommendation from the Behavior Health Specialist to receive psychotherapy was ever carried out to address the residents use of alcohol which the facility has correlated to the resident being found lying on the floor and subsequently lead to the resident sustaining harm (Subarachnoid Hemorrhage, Left Supracondylar Fracture and laceration below left eye brow). During a face-to-face interview on (MONTH) 14, (YEAR), at approximately 9:30 AM with the Psycologist #24 from (Behavioral Health Services Company), he stated, the company does not offer psychotherapy and he has not seen or treated this resident before. During a face-to-face interview on (MONTH) 14, (YEAR), at approximately 4:00 PM with the Employee #9, she acknowledged the findings.

Based on staff and resident interviews for one (1) of three (3) residents, it was determined that facility staff failed to notify the physician timely when the sacral wound deteriorated and additionally, the progression of an excoriated peri area. Resident #1 The findings include: Resident # 1 was admitted on (MONTH) 4, (YEAR). He/she was transferred to the hospital on (MONTH) 9, (YEAR) through (MONTH) 5, (YEAR) for rapid heart rate and difficulty breathing. Resident #1 was hospitalized on (MONTH) 25, (YEAR) for heavy amount of purulent drainage with odor from the sacroguteal wound and did not return to the facility. According to the Minimum Data Set (MDS) assessment with a target date of (MONTH) 25, (YEAR), Resident #1 scored 3/15 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 1-7 suggests that the resident has severely impaired cognitive skills for daily decision making. Resident #1was assessed as requiring extensive assistance for bed mobility, dressing, eating, and personal hygiene and totally dependent for transfers toileting and bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. Resident #1 received all of his/her nutrition through a Gastrostomy tube. A review of the Weekly Wound Report revealed the following: Sacral Wound June 6, (YEAR), measures 5 cm x 6 cm x 0.1 with 30% eschar (status upon admission) June 15, (YEAR), measured 5.0 cm x 6.0 cm x 0.1 with 30% eschar, unstageable June 22, (YEAR), measured 6.0 cm x 5.5 cm x 0.1 with 90% slough, unstageable June 29, (YEAR), measured 6.0 cm x 5.5 x 0.0, 90% slough, unstageable July 7, (YEAR), measured 9.5 cm x 6.5 cm x unstageable, 90% slough (MD notified (MONTH) 9, (YEAR)) July 13, (YEAR), measured 11.0 cm x 8.0 cm x unstageable with 90% slough July 20, (YEAR) measured 11.0 cm x 8.2 cm x unstageable with 90% slough There was no evidence that the physician was notified on (MONTH) 22, (YEAR), (MONTH) 13, (YEAR) or (MONTH) 20, (YEAR) when there was a change in the condition of the sacral wound. According to a nurse's note dated (MONTH) 9, (YEAR) at 14:06 (2:06 PM): .Wound is deteriorating. (MD) made aware and ordered Juven, Vitamin C and zinc for wound healing . There was no evidence in the wound nurse's progress notes or the interdisciplinary progress notes that the physician was notified of the resident's worsening wound. According to a nurse's note dated (MONTH) 25, (YEAR) at 13:28 (1:28 PM): Upon removing resident's old dressing from sacroguteal wound a very foul odor was noted. The dressing was opened and the wound was draining a heavy amount of purulent drainage with odor. V/S (vital signs) 103.5 (Temperature) R (Respirations) 24, B/P (Blood Pressure) 122/72, O2 sat 98%. (MD) was made aware and orders were given to transfer resident to ER to r/o (rule out)[MEDICAL CONDITION]. Nurse made aware to follow up. According to the nurses' notes the following vital signs were reviewed: July 20, (YEAR) at 11:00 AM: BP (Blood Pressure) 126/84, P (Pulse) 125, R (Respirations) 19, T (Temperature) 98.2 July 21, (YEAR) at 21:31 (9:31 PM): T 97.0, P-116, R 18, B/P 122/70, SA02 (Oxygen Saturation) 99% July 22, (YEAR) at 15:36 (3:36 PM): T-98.9, P-20, R 20, B/P 118/70, SA02 99% July 23, (YEAR) at 11:28 AM:B/P 116/78, p-124, T 98.3, R 19, SA02 97% via Trach July 24, (YEAR) at 4;16 AM: B/P 125.90, P- 90, R-18, T -97.8, 02 sat 98% July 25, (YEAR) at 3:45 AM: B/P 130/71, P 77, R 20, T 97.6, Sa02 98% May, (MONTH) and (MONTH) (YEAR) Treatment Administration Record (TAR) A review of the May, (MONTH) and (MONTH) (YEAR) TAR revealed that Mr. [NAME]' wound dressings were changed daily. Review of the wound nurse's progress notes revealed the following: June 7, (YEAR) at 14:38 (2:38 PM): Wound care done to unstageable sacroguteal wound moderate SS (serosanguinous) drainage noted tx (treatment) silver alginate. Right heel and left heel DTPI 100% intact tx skin prep and off-loading. No s/s (signs or symptoms) of pain. Plan of care air mattress, turn and repositioning and off-loading. June 12, (YEAR) at 14:00 (2:00 PM): Wound care done to unstageable wound moderate SS drainage noted tx silver alginate. Right heel and left heel DTPI (Deep Tissue Pressure Injury) 100% intact tx skin prep and off-loading. No s/s of pain. Plan of care air mattress, turn and repositioning and off-loading. June 19, (YEAR) at 13:48 (1:48 PM): Wound care done to unstageable sacroguteal wound 100% eschar noted moderate SS drainage noted tx Santyl and calcium alginate (change in treatment). Right heel and Left heel DTPI intact tx skin prep and off-loading. No s/s of pain. Plan of care air mattress, turn and repositioning and off-loading. June 21, (YEAR) at 15:10 (3:10 PM): Wound care done to unstageable sacroguteal wound 100% eschar noted moderate SS drainage noted tx Santyl and calcium alginate. Right heel and left heel DTPI 100% intact tx skin prep and off-loading. No s/s of pain. Plan of care air mattress, turn and repositioning and off-loading. (No entry for (MONTH) 22, (YEAR).) July 3, (YEAR) at 13:09 (1:09 PM): Wound care done to unstageable sacroguteal wound moderate SS drainage noted tx Santyl and calcium alginate. Peri area excoriation noted. Right heel and left heel DTPI intact tx skin prep and off-loading. No s/s of pain. Plan of care air mattress, turn and repositioning and off-loading. (No entry for (MONTH) 6, (YEAR).) July 9, (YEAR) at 11:41 AM: Wound care done to unstageable sacroguteal wound 95% necrotic 5% granulation, moderate SS drainage noted tx Santyl and calcium alginate. Peri area excoriation noted. Wound is deteriorating. Dr.[NAME]made aware and ordered Juven, Vitamin C and zinc for wound healing. Right heel and left heel DTPI 100% intact tx skin prep and off-loading. No s/s of pain. Plan of care air mattress, turn and repositioning and off-loading. July 11, (YEAR) at 13:35 (1:35 PM): Wound care done to unstageable sacroguteal wound 95% necrotic 5% granulation, moderate SS drainage noted tx Santyl and calcium alginate. Peri area excoriation noted. Right heel and left heel DTPI 100% intact tx skin prep and off-loading. No s/s of pain. Plan of care air mattress, turn and repositioning and off-loading. July 17, (YEAR) at 20:42 (10:42 PM): Wound care done to unstageable sacroguteal wound 95% necrotic 5 % granulation, moderate SS drainage noted tx Santyl and calcium alginate. Peri area excoriation noted. Right heel and left heel DTPI 100% intact tx skin prep and off-loading. No s/s of pain. Plan of care air mattress, turn and repositioning and off-loading. July 21, (YEAR) at 15:18 (3:18 PM): Wound care to unstageable sacroguteal wound moderate SS drainage noted tx Santyl and calcium alginate . peri area excoriation noted. Right heel and left heel DTPI 100% intact tx skin prep and off-loading. No s/s of pain. Plan of care air mattress, turn and re-positioning and off-loading. Review of physician's orders [REDACTED].>The following physician's orders [REDACTED].>June 6, (YEAR): Sacral wound - Cleanse with normal saline, apply silver alginate and cover with dry sterile dressing daily. Apply skin prep daily to left and right heels. June 19, (YEAR) at 13:48 (1:48 PM): .tx Santyl (chemical debrider) and calcium alginate (change in treatment) daily . According to www.nih.gov: [MEDICATION NAME] Santyl? Ointment is a sterile enzymatic [MEDICATION NAME] ointment which contains 250 [MEDICATION NAME] units per gram of white [MEDICATION NAME] USP. The enzyme [MEDICATION NAME] is derived from the fermentation by ,[MEDICAL CONDITION]. histolyticum. It possesses the unique ability to digest collagen in necrotic tissue. July 2, (YEAR) at 13:07 (1:07 PM): .Peri area excoriation noted. The excoriated peri area was noted in the wound nurse's progress notes dated (MONTH) 3, 4, 9, 10, 11, 12, 16, 18, 21, and 23, (YEAR). There was no evidence in the wound nurse's progress notes or the interdisciplinary progress notes that the physician was notified of the resident's status of the excoriated peri area after (MONTH) 2, (YEAR). There was no documentation in the resident's record that the physician had been notified of a change in condition of the sacral wound on (MONTH) 22, (YEAR), (MONTH) 13, (YEAR) and (MONTH) 20, (YEAR). There was no documentation in the wound nurse's progress notes or the interdisciplinary progress notes that the physician was notified regarding the condition of the excoriated peri area. Employee #1 acknowledged the above findings on (MONTH) 13, (YEAR). Resident #1 -[NAME][NAME] Employee #1 -[NAME]Onyeador, DON

Based on record review and staff interview for one (1) of 44 Stage 2 sampled residents, it was determined that facility staff failed to consistently assess and monitor the condition of Resident #227 ' s skin to ensure that necessary treatment and services were provided. Subsequently, the resident developed an Unstageable Sacral Pressure Ulcer that was initially identified at an advanced stage. The findings include: Policy: CLIN-027 Skin Care - Preventive Care; Revision date 3/21/16 (March 21, 2016) Purpose: To identify residents who are at risk for the development of skin breakdown. To provide nursing interventions to prevent skin breakdown whenever possible. Policy: 1. Residents will be assessed using the Braden scale (tool used for predicting pressure sore risk). On admission and readmission, quarterly, and whenever an (Minimum Data Set) MDS is completed for change of condition . 2. Nursing care measures will be instituted based upon the risk assessment score. An individualized care plan will be developed addressing the risk of and actual skin breakdown. 3. Newly admitted residents who are non-ambulatory and/or incontinent of bowel/bladder are considered at risk for skin breakdown and will have preventive measures initiated. 4. Resident ' s skin will be inspected daily by the GNC (G Nursing Assistant) and he/she will report abnormal findings to the nurse. 5. A nurse will assess the resident ' s skin condition weekly and document findings . Procedure 1. Residents who are incontinent will be checked at least every 2 hours and PRN (as needed) If soiled, perineal area will be cleansed using perineal cleaner. Pat dry 5. Residents who are dependent in bed/chair mobility will be turned and repositioned at least every 2 hours. Positioning devices will be used to avoid pressure on bony prominence and pressure over skin-to-skin contact surfaces (e.g., between knees). Procedure: .10. If identified by the Braden scale as risk, the following will be implemented: a. All general measures listed above in the policy, b. Pressure reduction mattress c. Pressure reduction cushion when OOB (out of bed) d. Dietary recommendations for nutritionally compromised resident e. Potential for Skin Breakdown will be identified as a problem on the care plan list f. Develop care plan to address individual needs . Resident #227 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. A review of the history and physical examination [REDACTED]. A review of the Admission Minimum Data Set (MDS) dated [DATE] revealed under Section G0110 Activities of Daily Living (ADL ' s) that Resident #227 was coded as (3) requiring that the resident needed extensive assistance of two (2) persons for bed mobility, transfer, dressing, toilet use personal hygiene, and bathing. Section G0600-Mobility Devices revealed the resident required a wheelchair for mobility and under Section H- Bladder and Bowel, Resident #227 was frequently incontinent of urine and always incontinent of bowels. Section M-Skin Conditions revealed the resident was coded in Section M0150 as at risk for developing pressure ulcers; M0210 the resident was coded as having no unhealed pressure ulcers upon admission. A review of the physician's order [REDACTED]. .Original order date July 18, 2016: (1) Barrier cream to buttocks for protection and miniaturization (moisturize) every shift, (2) Braden scale quarterly and PRN (as needed); (3) Braden scale weekly x 4 every evening shift, every mon (Monday) for 4 weeks), (3) turn and reposition, (4) weekly skin checks, turn and reposition every 2 hours and as needed, every shift; Order date July 18, 2016, start date July 25, 2016: Weekly skin check by licensed nurse every day shift every mon (document and notify MD/NP for new findings.) Order date August 2, 2016: Air mattress Order date August 8, 2016: Cleanse with Normal Saline, pat dry, apply Santyl followed by Calcium Alginate, cover with dry dressing . Order date August 20, 2016 transfer resident to ER for sacral eval (evaluation) for possible infection. Order date August 21, 2016 Transfer via Life Star as situation not an emergency . A review of the admission nursing assessment dated [DATE] 00:41 (12:41 AM) indicated that the resident ' s Skin integrity was normal color, temperature was warm and dry, skin turgor was normal and the resident did not have a pressure sore upon admission to the facility. The assessment also showed that the resident required extensive assistance with ADL ' s (Activities of Daily Living). A Braden Scale assessment (Used for predicting pressure sore risk) dated July 18, 2016 revealed that the resident scored 13 which indicated that the resident was at moderate risk for skin breakdown. The Braden Scale also revealed that the resident responds to verbal commands, has no sensory deficit which would limit ability to feel or voice pain or discomfort; occasionally moist which would require extra linen change .; Chairfast indicating the residents ' ability to walk was severely limited or non-existent .; Mobility was very limited indicating the resident makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. A review of Progress Notes dated July 19, 2016 revealed .Resident skin is warm and dry to touch, skin intact but for the right groin surgical site for the aortic dissection, which measures 1.5cm wide and 3cm long . Resident needs extensive assist with transfer and to be turn and reposition q (every) 2hr (hours) for pressure relief and for comfort . There was no evidence in the clinical record that Resident #227 was admitted to the facility with a sacral pressure sore. However, licensed staff documented the initial assessment of an unstageable sacral wound on August 2, 2016 as follows: A nurse's entry dated August 2, 2016 at 20:34 (2:34 AM), Late entry .Dr. (named) called and orders given. Cleanse sacral wound with normal saline, pat dry, apply hydrogel and cover with borders . A review of the facility ' s Weekly Wound Report revealed documentation recorded by the licensed nurse on August 2, 2016, ' unstageable pressure wound of the sacrum .size, 6x6x0.5 cm (centimeter) with 50% slough, 50% granulation, moderate serous sanguineous drainage . ' A review of the Activities of Daily Living Flowsheets (ADL tracking recorded by certified nurse assistants) for Resident #227 indicated that from July 18, 2016 through August 2, 2016 the resident was totally dependent on staff for bed mobility which included when the resident was turned and repositioned by staff; the resident did not have any behavior symptoms observed except for July 29, 2016 23:29 (11:39 pm) in which the resident was observed Yelling/screaming. Under the Skin Observation section, the resident was first identified with an open area by the CNA on July 30, 2016 at 21:15, July 31, 2016 at 19:49 (7:49 PM) and August 2, 2016 at 10:52 AM. The Bladder and Bowel Continence section revealed the resident was always incontinent, however the resident was provided incontinent care no more than once per shift. There was no evidence that the CNA informed the licensed nurse of the open area that was observed three (3) days prior to the Charge nurse ' s first assessment of the wound on August 2, 2016. A review of the Comprehensive CNA (Certified Nursing Assistant) Shower Review revealed that the resident was offered a bath, shower or bed bath on July 25, 2016, which he/she refused as evidenced by the word refused written on the line for reason and a check mark on the No line, no comments were noted in the Charge Nurse Assessment/Intervention section, however the charge did sign the sheet. On July 26, 2016 the resident received a shower as evidenced by a check mark on the line for shower, with the CNA ' s signature, no comments for assessment/intervention was made by the charge nurse although he/she signed the shower sheet. On July 28, 2016 the resident refused a bath, shower or bed bath as evidenced by a check mark on the space for No and the word refused was written on the line next to reason .the CNA's signature along with the charge nurse signature was noted on the sheet. However, there were no comments in space designated for the charge nurse assessment/interventions. The resident received a shower on July 30, as evidenced by the CNA ' s signature and check mark in the space for shower. The Charge nurse signed the sheet, however there were no comments in space designated for charge nurse assessment/interventions and there were no descriptions of any skin abnormalities identified on the body chart. On August 3, 2016 there was a check mark in the space for shower, as evidenced by the CNA ' s signature, however there was no description of the skin identifying the skin abnormality of the sacral area. The shower was given one (1) day after the wound was discovered. There were no comments made by the charge nurse in the Charge Nurse Assessment/Intervention section although the charge signed the sheet. There was no evidence in the clinical record that a pressure reduction mattress was implemented once the resident was assessed with [REDACTED]. The pressure reduction mattress, according to the physician's order [REDACTED]. A face-to-face interview was conducted on October 24, 2016 with Employee #6 at approximately 11:20 AM. He/she stated that the resident did not have any skin breakdown upon admission, the resident was a very skinny (small framed) person and the resident would like to sit up for long periods of time. A face-to-face interview was conducted on October 24, 2016 with Employee #22 at approximately 3:00 PM. He/she stated that he/she saw the resident on August 16, 2016 the resident was non-compliant, (his/her) condition went down fast. I saw the resident when I was contacted by staff to see the resident. A face-to-face interview was conducted on October 24, 2016 with Employee #28 at approximately 10:15 AM. He/she stated that he/she took care of the resident on July 30, 2016 which the resident had (his/her) wound before I did ADL on (him/her.) A face-to-face interview was conducted on October 24, 2016 with Employee #29 at approximately 10:55 AM. He/she stated the last I cared for (Resident #227) was on July 22, 2016, there was no wound. The end of July (July 28, 2016) there was a very little skin tear. The clinical record lacked evidence that facility staff consistently assessed and monitored the condition of Resident #227 ' s skin although the resident was identified as a moderate risk for skin breakdown. Resident #227 sustained a facility acquired unstageable pressure wound of the sacrum approximately 2 weeks following admission. The record was reviewed October 24, 2016.

Based on record review and staff interviews for Resident #1, it was determined that facility staff failed to adequately monitor the resident ' s PT/INR while taking [MEDICATION NAME] and [MEDICATION NAME]. Subsequently, the resident was hospitalized after coughing up blood. The findings include: Resident #1 was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment with an assessment reference date of September 15, 2015, he/she scored 15/15 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 13-15 suggests that the resident is cognitively intact. Resident #1 was assessed as requiring extensive assistance for bed mobility, transfers, dressing, eating, toilet use and personal hygiene and totally dependent for bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated October 6, 2015 at 23:40 (11:40 PM): Lab Results: Resident is alert and verbally responsive, no apparent distress noted during shift. Lab result for Uric Acid received during shift, Uric Acid was 9.7 (elevated). Dr. Williams notified new orders given: 1) [MEDICATION NAME] 25 mg PO BID x 5 days for gout 2) [MEDICATION NAME] 100 mg 1 tablet everyday for gout starting on 10/9/15 Resident notified of new orders resident verbalized understanding. Unable to reach RP Ernest Kressy. According to a nurse ' s note dated October 7, 2015 at 17:55 (5:55 PM): Resident complaining pain to the Right Great toe. She reported pain level 6/10. New medication [MEDICATION NAME] for gout was also administered for pain. According to a nurse ' s note dated October 12, 2015 at 18:22 (6:22 PM): Resident complaining of numbness & weakness to the left arm and she was noted coughing up blood. PT/INR result drawn today, INR was 10. Dr. Williams made aware and an order was made to send pt to ER for evaluation. 911 called & resident was sent to WHC. Resident ' s husband Ernest Kressy made (aware). V/S 190/88, 97.6, 79, 20. The following monthly pre-printed orders were signed by the physician on October 6, 2015: [MEDICATION NAME] tab 2.5 mg Give 1 tablet orally one time a day every Sun, Fri and Sat for [MEDICAL CONDITION] [MEDICATION NAME] tab 5 mg Give 1 tablet orally one time a day every Mon, Tues, Wed, Thu for [MEDICAL CONDITION] The following orders were written by the physician dated October 6, 2015 at 7:00 PM: [MEDICATION NAME] 25 mg PO BID x 5 days for gout; [MEDICATION NAME] 100 mg po Q D for gout Start 10-19-15 According to www.nih.gov <http://www.nih.gov>; It is recommend that the [MEDICATION NAME] time is observed closely when [MEDICATION NAME] is given to a patient receiving oral anticoagulants. Apart from individual interaction with [MEDICATION NAME] there is, of course, always a danger that patients on non-steroidal anti-[MEDICAL CONDITION] drugs may develop [MEDICAL CONDITION], and this is a further point to bear in mind before undertaking anticoagulation. There was no evidence that the physician ordered additional monitoring of the resident ' s INR levels when the [MEDICATION NAME] was prescribed. A face-to-face interview was conducted with Employee #1 on October 15, 2015 at 11:30 AM who acknowledged the above findings. The record was reviewed October 15, 2015.

Based on record review and staff interview for two (2) of 68 sampled residents, it was determined that facility staff failed to ensure that residents were free from physical abuse as evidenced by Residents #172 and 153 who each sustained two (2) occasions of physical abuse. The findings include: 1. Facility staff failed to ensure that Resident #172, who was hit with an object thrown by Resident #220 on two (2) occasions was free from physical abuse. Subsequently, the resident sustained [REDACTED]. A review of the team notes (includes but is not limited to progress notes recorded by nursing, dietary, social services and activity staff) revealed the following: Nurse ' s entry, May 28, 2013 at 3:00 PM, " The (Resident #172) was (struck) in the dining room with at plate and a cup of coffee on (his/her) left upper arm. MD (medical doctor) notified, order to clean with NSS (normal saline solution) and apply [MEDICATION NAME] (and cover) till (until) healed. Resident stable, RP notified ... " Social worker entry, May 29, 2013, " SW (social worker) spoke with resident (Resident #172) s/p (status [REDACTED]. Resident stated, ' I did not do anything to (Resident #220), (he/she) threw a cup. " Nurse ' s entry, October 16, 2013 at 7:00 PM, " At about 2:00 PM CNA(Certified Nurse Aide) (Name) reported to the writer (Name) that (he/she) observed (Resident #220) threw a plate at another (Resident #172) on his/her left head and shouting in a foreign language. This happened in the 1st floor dining room. On assessment resident was bleeding with a laceration on his/her head measuring 3.5 cm x 0.3 cm x 0.1 cm, PA (physician assistant) notified order obtained to clean site with NSS, applied pressure dressing and sent resident to ER (emergency room ) for treatment. Police was notified ... " Nurse ' s entry, October 17, 2013 at 7:00 AM, " Resident was brought back to the unit at 12:05 AM from (Hospital) ER ...Assessment was done, a stitched scalp laceration measuring L (length 3 cm x W (width) 0.3 cm, 9 staples was noted on the l (left) parietal side of the head. CT scan of the head without contrast done at (Hospital) r/o (rule out), no acute intracranial findings ... " A review of the physician's orders [REDACTED]. A review of the clinical record lacked evidence that neurological assessments were conducted after the incident and post the resident ' s return from the hospital after he/she sustained head trauma. Witness Statement A review of the facility ' s investigation regarding the altercation that occurred on October 16, 2013 between Resident #172 and Resident #220 included the following " Witness Statement " dated October 16, 2013 (no time indicated): " When I was entering the cafeteria (first floor dining room) another staff member was saying to get (Resident #220) he/she had threw a plate at (Resident #172 ' s) head, then I witnessed (Resident #220) pick up another plate (and) hit (him/her) in the back of (his/her) head as (Resident #172) was trying to exit the cafeteria shouting something in another language. When I looked at (Resident #172) head as (he/she) was leaving (his/her) head was bleeding. By then (Resident #220) was exiting the cafeteria still shouting and (Resident #172) was refusing care. " A review of the Care Plan section of Resident #172 ' s clinical record revealed: A care plan initiated May 28, 2013 (page 5 of 16), entitled, "On May 28, 2013 another resident in (room number #) (Resident #220) throw a plate and a cup of coffee on resident right upper arms. " Resident was noted with abrasion on the right upper arm. " " Goal: resident will be safe for 90 days. Interventions: Resident will eat in room during meals to keep both residents separated. " On October 16, 2013 a hand written entry was recorded on the care plan (on page 4 of 16) entitled, " Resident presents as needing 24 hours of care and supervision secondary to [DIAGNOSES REDACTED]. Resident in (room number #_) (Resident #220) threw a plate on (his/her) L (left) head. Resident was noted with laceration measuring 3.5 cm x 0.3 cm x 0.1 cm). " A face-to-face interview was conducted with Employee # 5 and Employee #21 (Physician Assistant) on November 1, 2013 at approximately 10:35 AM. Employee #21 stated, "The resident (Resident #172) was agitated. (He/she( would not go with EMS (emergency medical services) to the hospital. (He/she) was bleeding and agitated. I gave a verbal order to transfer the resident to the hospital (on October 16, 2013 post altercation). I did not write the order." Employee #5 acknowledged that there was no order to transfer Resident #172 to the hospital and there was no neurological assessment was conducted prior to the resident ' s transfer to the hospital or upon his/her return from the hospital. Employee #5 acknowledged that a care plan was in place to keep the resident in his/her room during meal times. However, on October 16, 2013 (the date of the altercation), Resident #172 was in the dining room. Employee #5 further acknowledged that Resident #172 sustained an injury from a prior altercation with Resident #220 on May 28, 2013 wherein he/she was struck with a plate that had been thrown. Facility staff failed to consistently implement the " safety " care plan that the interdisciplinary team (IDT) developed May 28, 2013, " resident will eat in room during meals to keep both resident separated ... " Subsequently, Resident #172 sustained a head injury that required emergent medical treatment secondary to intentionally being struck in the head with a chinaware plate by Resident #220." A similar incident (plate thrown) involving Resident #220 against Resident #172 occurred approximately five (5) months prior, on May 28, 2013 wherein Resident #172 sustained an injury to his/her arm. The facility staff failed to implement measures to ensure that Resident #172 was free from physical abuse. The record was reviewed November 1, 2013. 2. Facility staff failed to ensure that Resident #153 was free from physical abuse by another resident (Resident #340) on two (2) occasions. A review of the quarterly Minimum Data Set completed August 8, 2013 revealed under Section G (Functional Status), Resident #153 was coded as requiring supervision and one (1) person physical assist for bed mobility, supervision and set up for transfer, and eating. The care plan entitled, " Problematic Manner in which resident acts characterized by ineffective coping; agitation related to Psychiatric illness [MEDICAL CONDITION] and [MEDICAL CONDITION] disease " initiated on April 29, 2013 revealed, " ...Interventions: created on September 27, 2013, Resident is on one on one monitoring. Created on October 21, 2013, Resident relocated to (room number#) to ensure (his/her) safety. " A review of the team notes (includes but is not limited to progress notes recorded by nursing, dietary, social services and activity staff) and the interim physician ' s orders in Resident #153 ' s clinical record revealed the following: Team Note (written by nursing)-September 25, 2013 2:15 PM, " (Resident #153) was involved in a physical altercation with another (Resident #340). (Resident #340) complained that (his/her) roommate told (him/her) that (Resident #153) came to (his/her) room in (his/her) absence and ate (his/her) snacks. (Resident #153) said (he/she) does not know what (Resident #340) is talking about when asked by staff. (Resident #153) complaint of pain on (his/her) breast as a result of a kick by (Resident #340). Upon assessment no observable injury noted. Was informed by writer order was given to do cold compress and administer Tylenol for pain. RP (responsible party) was informed by writer. Nursing Supervisor called the police. " Interim physician's order [REDACTED]. " Team Note (written by nursing)--October 17, 2013 at 3:40 PM, " 1:1 monitoring discontinued per unit manager order (name of staff person). Resident remains stable and verbally responsive. No complaint of discomfort voiced by resident. " Interim physician's order [REDACTED]. " Team Note (written by nursing) - October 19, 2013 at 6:30 PM, " (Resident #153) was in (his/her) room at 3:45 PM when another (Resident #340) came into (his/her) room and began accusing (his/her) of stealing from (his/her). (Resident #340) began kicking (Resident #153) on (his/her) chest and stomach; both were separated from one another. PMD (primary medical doctor) called at 4:08 PM. Police were called ...1:1 monitoring for 72 hours continued. " Interim physician's order [REDACTED].#153) to be 1:1 monitoring for 72 hours. " According to a nurse ' s entry dated September 26, 2013, " (Resident #153) was placed on one-to-one monitoring as an intervention by the facility to keep the resident safe. " However, this order was discontinued on October 17, 2013 at 3:40 PM. (Residents #153) and (Resident #340) continued to reside on the same hallway on the same unit. According to the " Report of Consultation " dated October 5, 2013, it was known by the facility that (Resident #340 ' s) medical history included [MEDICAL CONDITION] Depression, Alcohol Dependence and Impulsive Control D/O (disorder). (Resident #153) was not safeguarded from (Resident #340) with known behaviors and history of resident-to-resident altercation." Interim physician's order [REDACTED]. There was no evidence that facility staff consistently implemented interventions to ensure that Resident #153 was free from physical abuse. He/she was assaulted (kicked and punched) by Resident #340 on September 26, 2013 and was observed being kicked by Resident #340 for the second time on October 19, 2013 two (2) days after the one-to-one monitoring was discontinued. A face-to-face interview was conducted with the Employees #2 and #12 on November 12, 2013 at approximately 10:45 AM. It was stated that Resident #153 was placed on one-to-one (monitoring). Psych (psychiatrist) came in to see Resident #340 on October 17, 2013. The record was reviewed on November 12, 2013.

Based on record review and staff interview for two (2) of 68 sampled residents, it was determined that facility staff failed to ensure that residents received adequate supervision as to avoid and/or prevent resident-to-resident altercations as evidenced by one (1) resident who sustained two (2) episodes of assault with injury by another resident (Resident #172 vs. Resident #220) and one resident that sustained two (2) episodes of physical assault by another resident (Resident #153 vs. Resident #340). Residents #172 and #153. The findings include: 1. Facility staff failed to provide adequate supervision to Resident #172 who was hit with an object thrown by Resident # 220 on two (2) occasions. Subsequently, the resident sustained [REDACTED]. A review of the team notes (includes but is not limited to progress notes recorded by nursing, dietary, social services and activity staff) revealed the following: Nurse ' s entry, June 28, 2013 at 3:00 PM, " The resident was (struck) in the dining room with at plate and a cup of coffee on (his/her) left upper arms. MD (medical doctor) notified, order to clean with NSS (normal saline solution) and apply Bacitracin (and) (cover) till (until) healed. Resident stable, RP notified ... " Social worker entry, June 29, 2013, " SW (social worker) spoke with resident (Resident #172) s/p (status [REDACTED]. Resident stated, ' I did not do anything to (Resident #220), (he/she) threw a cup. " Nurse ' s entry, October 16, 2013 at 7:00 PM, " At about 2:00 PM CNA(Certified Nurse Aide) (Name) reported to the writer (Name) that (he/she) observed (Resident #220) threw a plate at another (Resident #172) on his/her left head and shouting in a foreign language. This happened in the 1st floor dining room. On assessment resident was bleeding with a laceration on his/her head measuring 3.5 cm x 0.3 cm x 0.1 cm, PA (physician assistant) notified order obtained to clean site with NSS, applied pressure dressing and sent resident to ER (emergency room ) for treatment. Police was notified ... " Nurse ' s entry, October 17, 2013 at 7:00 AM, " Resident was brought back to the unit at 12:05 AM from (Hospital) ER ...Assessment was done, a stitched scalp laceration measuring L (length 3 cm x W (width) 0.3 cm, 9 staples was noted on the l (left) parietal side of the head. CT scan of the head without contrast done at (Hospital) r/o (rule out), no acute intracranial findings ... " A review of the physician's orders [REDACTED]. A review of the clinical record lacked evidence that neurological assessments were conducted after the incident and post the resident ' s return from the hospital after he/she sustained head trauma. Witness Statement A review of the facility ' s investigation regarding the altercation that occurred on October 16, 2013 between Resident #172 and Resident #220 included the following " Witness Statement " dated October 16, 2013 (no time indicated): " When I was entering the cafeteria (first floor dining room) another staff member was saying to get (Resident #220) he/she had threw a plate at (Resident #172 ' s) head, then I witnessed (Resident #220) pick up another plate (and) hit (him/her) in the back of (his/her) head as (Resident #172) was trying to exit the cafeteria shouting something in another language. When I looked at (Resident #172) head as (he/she) was leaving (his/her) head was bleeding. By then (Resident #220) was exiting the cafeteria sill shouting and (Resident #172) was refusing care. " A review of the Care Plan section of Resident #172 ' s clinical record revealed: A care plan initiated May 28, 2013 (page 5 of 16), entitled, "On May 28, 2013 another resident in (room number #) (Resident #220) throw a plate and a cup of coffee on resident right upper arms. " Resident was noted with abrasion on the right upper arm. " " Goal: resident will be safe for 90 days. Interventions: Resident will eat in room during meals to keep both residents separated. " On October 16, 2013 a hand written entry was recorded on the care plan (on page 4 of 16) entitled, " Resident presents as needing 24 hours of care and supervision secondary to [DIAGNOSES REDACTED]. Resident in (room number #) (Resident #220) threw a plate on (his/her) L (left) head. Resident was noted with laceration measuring 3.5 cm x 0.3 cm x 0.1 cm). " A face-to-face interview was conducted with Employee # 5 and Employee #21 (Physician Assistant) on November 1, 2013 at approximately 10:35 AM. Employee #21 stated, "The resident (Resident #172) was agitated. He/she would not go with EMS (emergency medical services) to the hospital. (He/she) was bleeding and agitated. I gave a verbal order to transfer the resident to the hospital (on October 16, 2013 post altercation). I did not write the order." Employee #5 acknowledged that there was no order to transfer Resident #172 to the hospital and there was no neurological assessment was conducted prior to the resident ' s transfer to the hospital or upon his/her return from the hospital. Employee #5 acknowledged that a care plan was in place to keep the resident in his/her room during meal times. However, on October 16, 2013 (the date of the altercation), Resident #172 was in the dining room. Employee #5 further acknowledged that Resident #172 sustained an injury from a prior altercation with Resident #220 on May 28, 2013 wherein he/she was struck with a plate that had been thrown. Facility staff failed to consistently implement the " safety " care plan that the interdisciplinary team (IDT) developed May 28, 2013, " resident will eat in room during meals to keep both residents separated ... " Subsequently, Resident #172 sustained a head injury that required emergent medical treatment secondary to intentionally being struck in the head with a chinaware plate by Resident #220. A similar incident (plate thrown) involving Resident #220 against Resident #172 occurred approximately five (5) months prior, on May 28, 2013 wherein Resident #172 sustained an injury to his/her arm after being struck intentionally by a plate. The facility staff failed to provide adequate supervision to ensure that Resident #172 was free from physical abuse. The record was reviewed November 1, 2013. 2. Facility staff failed to provide adequate supervision for Resident #153 who was physically assaulted by the same resident (Resident #340) on two (2) occasions. A review of the quarterly Minimum Data Set completed August 8, 2013 revealed under Section G (Functional Status), Resident #153 was coded as requiring supervision and one (1) person physical assist for bed mobility, supervision and set up for transfer, and eating. The care plan entitled, " Problematic Manner in which resident acts characterized by ineffective coping; agitation related to Psychiatric illness Schizophrenia and Bipolar disease " initiated on April 29, 2013 revealed, " ...Interventions: created on September 27, 2013, Resident is on one on one monitoring. Created on October 21, 2013, Resident relocated to room 244 B to ensure (his/her) safety. " A review of the team notes (includes but is not limited to progress notes recorded by nursing, dietary, social services and activity staff) and the interim physician ' s orders in Resident #153 ' s clinical record revealed the following: Team Note (written by nursing)-September 25, 2013 2:15 PM, " Resident (#153) was involved in a physical altercation with another resident (#340). Resident (#340) complained that (his/her) roommate told (him/her) that (Resident #153) came to (his/her) room in (his/her) absence and ate (his/her) snacks. (Resident #153) said (he/she) does not know what (Resident #340) is talking about when asked by staff. (Resident #153) complaint of pain on (his/her) breast as a result of a kick by (Resident #340). Upon assessment no observable injury noted. Was informed by writer order was given to do cold compress and administer Tylenol for pain. RP (responsible party) was informed by writer. Nursing Supervisor called the police. " Interim physician's order [REDACTED]. " Team Note (written by nursing)--October 17, 2013 at 3:40 PM, " 1:1 monitoring discontinued per unit manager order (name of staff person). Resident remains stable and verbally responsive. No complain of discomfort voiced by resident. " Interim physician's order [REDACTED]. " Team Note (written by nursing) - October 19, 2013 at 6:30 PM, " (Resident #153) was in (his/her) room at 3:45 PM when another (Resident #340) came into (his/her) room and began accusing (his/her) of stealing from (his/her). (Resident #340) began kicking (Resident #153) on (his/her) chest and stomach; both were separated from one another. PMD (primary medical doctor) called at 4:08 PM. Police were called ...1:1 monitoring for 72 hours continued. " Interim physician's order [REDACTED].#153) to be 1:1 monitoring for 72 hours. " According to a nurse ' s entry dated September 26, 2013, " (Resident #153) was placed on one-to-one monitoring as an intervention by the facility to keep the resident safe. " However, this order was discontinued on October 17, 2013 at 3:40 PM. (Residents #153) and (Resident #340) continued to reside on the same hallway on the same unit. According to the " Report of Consultation " dated October 5, 2013, it was known by the facility that Resident #340 ' s medical history included Bipolar Depression, Alcohol Dependence and Impulsive Control D/O (disorder). Resident #153 was not safeguarded from (Resident #340) with known behaviors and history of resident-to-resident altercation. Interim physician's order [REDACTED]. There was no evidence that facility staff consistently implemented interventions to ensure that Resident #153 was free from physical abuse. He/she was assaulted (kicked and punched) by Resident #340 on September 26, 2013 and was observed being kicked by Resident #340 for the second time on October 19, 2013 two (2) days after the one-to-one monitoring was discontinued. A face-to-face interview was conducted with the Employees #2 and #12 on November 12, 2013 at approximately 10:45 AM. It was stated that Resident #153 was placed on one-to-one (monitoring). Psych (psychiatrist) came in to see Resident #340 on October 17, 2013. The facility staff failed to provide adequate supervision to ensure that Resident #153 was free from physical abuse. The record was reviewed on November 12, 2013.

Based on record review and staff and resident interviews, it was determined that facility staff failed to protect Resident #2 from sexual abuse from Resident #1. The findings include: Resident #1 was born on January 23, 1973 and was admitted to the facility on [DATE]. According to the Minimum Data Assessment (MDS) dated [DATE], Resident #1 achieved a score of 15/15 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 " 13-15 " suggests that the resident is " cognitively intact. " Resident #1was assessed as being independent for walking; requiring supervision for bed mobility, transfers, dressing, eating, toilet use; and extensive assistance for bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. According to the following nurses ' notes: March 11, 2013 at 2:00 AM: " Upon round making this writer found Resident #1 naked without wearing anything on and was standing in the room close to the door. This writer asked him/her to put on something to cover him/herself, a gown was provided he/she threw it on the floor and another one was given and he/she took it and started doing like have illusions/[MEDICAL CONDITION] symptoms. He/she later laid down in bed and remained on his bed. " March 18, 2013 at 10:34 AM: " Resident #1 and Resident #3 had a verbal altercation regarding the cord to Resident #3 ' s charger for his/her wheelchair being broken. Resident #3 angrily accused Resident #1 of breaking the cord to the wheelchair ' s charger. SW interviewed Resident #1 regarding this incident and he/she denies doing anything to Resident #3 ' s cord to his/her wheelchair charger. SW reminded the resident to allow staff to intervene for him/her when verbal altercation occurs in the future. Resident #1 also agrees to relocate to another floor when possible. Clinical manager is aware of this incident and an incident report was generated. " March 24, 2013 at 5:00 AM: " Resident #1 is alert and very responsive resident. Roommate called this writer while he/she was attending to the (roommate) that he/she feels tired and funny. This writer went to the (roommate) in room to check his/her blood sugar and see if he/she is okay. Resident #1 saw this writer when he/she came over to (roommate) because he/she pulled his/her overhead light on and quickly turn it off while this writer was checking (roommate ' s) blood sugar. Resident #1 used his/her leg to hit this writer in his/her buttocks and started laughing. When the nurse asked why he/she did that Resident#1 stated because " I am retarded and you are also. " This writer redirected Resident #1 (who) started talking and yelling to him/herself as if he/she is hearing voices PMD and R/P left messages for. " March 24, 2013 at 6:15 AM: " Supervisor on the unit at this time went to the Resident #1 and asked him/her why he/she used his/her leg to hit the writer ' s buttocks and he/she apologized that he/she did not do it intentionally. " May 7, 2013 at 9:30 PM: " Resident #1 is alert and verbally responsive. Received a call from the supervisor that the resident is saying FU ... word then Resident #4 pushed Resident #1 ' s hand with a cup of coffee and spilled it on Resident #1 ' s hand and cup dropped on the floor. On assessment no burns, injury on Resident #1 ' s hand and denies pain. MD made aware. RP notified. Resident #1 kept calm and safe. Stable at this time V/S (vital signs) BP (Blood Pressure) 122/76, R (Respirations) 18, P (Pulse) 78, T (Temperature) 97.8? " May 8, 2013 at 1:45 PM: " Resident #1 was interviewed (by Social Worker) regarding the physical altercation between him/her and Resident #4. Resident #1 said " I was just talking to myself and he/she thought I was talking to him/her and he/she pushed my coffee out of my hand. " SW counseled the resident to allow staff to assist him/her if something like this happens again. He/she said " alright " ADON is aware of the incident and an incident report will be generated. " May 10, 2013 at 2:00 PM: " Resident #1 is alert and responsive. Signed out self at 1:30 PM. " May 10, 2013 at 11:00 PM: " Resident #1 remains out on pass (OOP) Resident signed self out at 1:30 PM - morning shift going to (address). (Mother) made aware (Resident #1) is OOP. RP made aware by leaving a message that she signed a paper giving (Resident #1) authority to go out of (Facility) and to return. RP made aware by leaving a message that member of customer service working in this facility saw (Resident #1 at an address) in between (Street) and the shoe repair center drinking and smoking and does not want to come home to the facility yet. Supervisor made aware. In-coming shift please follow up. " May 11, 2013 at 2:40 PM: " At 1:40 AM Resident #1 returned to the unit from OOP he/she came in by him/herself and refused to be assessed. Also refused V/S to be taken on him/her. He/she was very agitated and loud and PMD made aware. He/she gave telephone order to transfer resident to the nearest ER for proper evaluation 911 activated at 2 AM resident was transferred to (hospital) as ordered. Resident #1 acknowledged that he/she had some " liquor " in the street ... " May 11, 2013 at 2:00 PM: " Resident #1 alert and verbally responsive returned to the unit from (hospital) at 1:00 PM. BP 130/70, T - 98.7, R- 20, P 80 ... " May 23, 2013 at 2:30 PM: " Resident #5 was in the bathroom. Resident #1 went to the bathroom following Resident #5 to the bathroom. Resident #5 said that he/she is being threatened by Resident #1 (who) said that he/she will shot him/her with his/her gun. Resident #5 called the police. (Police Officer) of District 7, responded and came in the unit. Interviewed Resident #1. Police officer asked Resident #1 where is your gun. Resident #1 answered it ' s here pointing to his/her private part. Police officer spoke to Resident #5 and explained that Resident #1 has no gun and he/she is only joking about it. Resident #5 felt relief both residents stable. R/P notified. " May 23, 2013 at 3:30 PM: " Resident #1 had verbal altercation with Resident #6 at the nurse station. There is no physical contact. Both residents were separated to their rooms. R/P notified by message. MD notified. Resident #1 stable. " June 6, 2013 at 11:00 PM: " Resident room changed from (room number) to (room number) due to incompatibility of roommate. R/P notified. PMD made aware ... " June 7, 2013 at 2:00 AM: " Resident #1 alert and very responsive during shift change rounds. Writer noted this resident put the heater to 95?. He/she was instructed to lower it down since it ' s too hot and his roommate was sweating excessively. Request a CNA to monitor him q 15 min. At 12:45 AM the CNA went to the room, knocked at the door and opened it. Noted that resident ran from roommate (Resident #2) side of the room to bathroom and started using toilet water to clean him/herself. This writer went to the room; roommate ' s (Resident #2) diaper was opened. Feces were all over roommate ' s body and his bedding. Resident #1 was also assessed and had feces from stomach area to the perianal area. Writer asked him/her what he was doing. He/she said washing and became loud. PMD made aware and gave telephone order to place him/her on 1:1 care until tomorrow. He/she will call the facility. R/P made aware. Resident #1 refused vital signs. " June 7, 2013 at 8:00 AM: " Resident #1 alert. At 6:05 AM police and ambulance on the unit based on fact that during the second round of assessment his roommate ' s (Resident #2) anal area was widely opened. At this time, Resident #1 is still resting quietly. " June 7, 2013 at 10:00 AM: Resident #1 alert and very responsive. He/she was taken out of the unit by the Department of Police for interrogation at sexual crime unit downtown DC. R/P message left. Expecting her call back and change of status done. PMD made aware. " Resident #7 was the roommate to Resident #1 from November 9, 2012 (Resident #1 ' s admission) until November 23, 2012. Resident #7 was born on June 1, 1944 and was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment completed October 2, 2012, Resident #7 achieved a score of 12/15 on the Brief Interview for Mental Status (BIMS) in Section C (Cognitive Patterns). According to the " MDS 3.0 User ' s Manuel " page C-14, a score of " 8-12 " suggests that the resident is " mildly cognitively impaired. " Resident #7 was assessed as being independent with bed mobility, transfers, walking, eating and toileting and required supervision for dressing and personal hygiene and totally dependent for bathing and used a wheelchair for mobility in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. On November 18, 2012, Resident #1 complained that Resident #7 hit him/her on the face three (3) times. Resident #1 was relocated to (first room available) on November 23, 2012 and his/her roommate was Resident #5. Resident #5 was the roommate to Resident #1 when they resided in (room) from November 23, 2012 until May 23, 2013. Resident #5 was born on February 19, 1949 and was admitted to the facility on [DATE]. According to the MDS assessment dated [DATE], Resident #5 achieved a score scored of 15/15 on the BIMS in Section C. According to the " MDS 3.0 User ' s Manuel " page C-14, a score of " 13-15 " suggests that the resident is " cognitively intact. " Resident #5 was assessed as being independent for eating; requiring supervision for bed mobility, transfers, eating, and toilet use; limited assistance for dressing; extensive assistance for personal hygiene and totally dependent for bathing and used a wheelchair for mobility in Section G. Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated May 23, 2013 at 2:30 PM: " Resident #5 was in the bathroom. Resident #1 went to the bathroom following Resident #5 to the bathroom. Resident #5 said that he/she is being threatened by Resident #1 (who) said that he/she will shot him/her with his/her gun. Resident #5 called the police. (Police Officer) of District 7, responded and came in the unit. Interviewed Resident #1. Police officer asked Resident #1 where is your gun. Resident #1 answered it ' s here pointing to his/her private part. Police officer spoke to Resident #5 and explained that Resident #1 has no gun and he/she is only joking about it. Resident #5 felt relief both residents stable. R/P notified. " On May 23, 2013, Resident #1 was transferred from (room to room) and his/her roommate was Resident #8 Resident #8 became the roommate when he/she entered the facility on May 23, 2013 until June 6, 2013. Resident #8 was born on November 19, 1937. According to the admission MDS, Resident #8 achieved a score of 15/15 on the BIMS in Section C. Resident #8 was assessed as being independent for eating, requiring supervision with walking in the room, extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and totally dependent for bathing in Section G. Disease [DIAGNOSES REDACTED]., and Acute Kidney Failure. A telephone interview was conducted with Employee #1 on July 17, 2013 at 11:30 AM. He/she was asked about the above cited relocation and stated, " Resident #8 told me that Resident #1 played his/her music too loudly and that he/she was always talking to him/herself. So we moved Resident #1 to (room). " On June 6, 2013, Resident #1 was transferred to (room) and his roommate was Resident #2. Resident #2 was the roommate on June 6, 2013. He/she was born on July 13, 1953 and was admitted to the facility on [DATE]. According to the Minimum Data Set assessment dated [DATE], Resident #2 was assessed with [REDACTED]. Resident #2 was assessed as requiring extensive assistance for bed mobility, eating, and totally dependent for transfers, dressing, toilet use, personal hygiene and bathing in Section G. Disease [DIAGNOSES REDACTED]. Observation of Resident #2 was conducted on June 11, 2013 at 10:15 AM. Resident #2 was observed in a geri-chair in the day room. Resident #2 was asked if anyone had hurt or harmed him. Resident #2 responded in a soft voice and mumbled incoherently. Resident #2 had contractures of bilateral arms and bilateral legs. According to a nurse ' s noted dated June 7, 2013 at 7:00 AM: " Resident #2 alert at 12:45 AM when one of the assigned caregiver ' s went to check on him/her, saw the roommate (Resident #1) run out of his/her bedside into the bathroom and start using toilet water to wash his/her perineal area. The writer went in the room and the resident ' s diaper was open and feces were all over the resident, his/her bedding and everywhere. Resident was asked what happened. He/she was unable to explain nothing. He/she was assessed with [REDACTED]. Bedding was saved for evidence. Resident was cleaned up. PMD made aware. Gave order to monitor resident closely and place roommate on 1:1 care. Unable to reach R/P at this time. Several calls made but line busy. At 6 AM resident was reassessed and his anal area was widely opened. 911 and police called to the unit by Clinical Manager. " June 7, 2013 at 7:30 AM: " At 6:05 AM police and ambulance arrived at the unit. Officers (badge numbers) were given report and answers were provided accordingly. At 7:17 AM resident was transferred to (hospital) for proper evaluation. Change of status done. Still unable to reach R/P at this time. Report will be given to on-coming shift to follow up with R/P. " A face-to-face interview was conducted with Employee #3 on June 11, 2013 at 5:00 AM. He/she was asked about the above concerns and stated, " The CNAs put Resident #2 in the geri-chair so we could clean up his/her bed and we took him/her to the nursing station. Resident #1 was placed one-to-one for the rest of the shift. " According to Resident #1 ' s Care Plan, the following problems were noted: " Focus: problematic manner in which resident acts characterized by inappropriate sexual behavior (Verbal and physical) related to: resident touches other residents and/or staff inappropriately. Resident used his leg and hit charge nurse on buttocks 3/24/13. Resident said to roommate that he/she will shoot him/her with a gun. When asked where is the gun, he/she pointed to his/her private parts. 6/7/13 Resident ran out from his/her roommate ' s side with feces all over him/her to the bathroom using toilet water to clean him/herself and with feces from his/her stomach to perineal area. " Care plan problem was initiated on March 25, 2013 and revised (updated) on May 24, 2013 and June 7, 2013. " Goals: (1) Reduce incidents of inappropriate sexual behaviors; initiated on March 25, 2013 and revised (reviewed) March 25, 2013. (2) Resident will carry out sexual behavior with self only in privacy of own room; initiated on May 24, 2013. Interventions: ? Distract resident if possible; initiated 3/25/ 2013 ? Document a summary of each episode; initiated on 3/25/ 2013 ? Police was called in the building 5/23/13; initiated 5/24/ 2013 ? Psych consult; initiated 3/25/ 2013 ? Remove resident from public area when behavior is disruptive/unacceptable. Talk with resident in low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity; initiated 3/25/2013 ? Resident relocated to different room [ROOM NUMBER]/23/13; initiated 5/24/2013 ? Set limits for acceptable behavior; Care plan initiated 3/25/2013 "Focus: Problematic manner in which resident acts characterized by ineffective coping; agitation related to: Anxiety resident had verbal altercation with other resident in the hallway on 1/4/13. Resident had a verbal altercation with another (Resident #3) on 3/15/13. Resident had verbal altercation with another (Resident #4 on May 7, 2013). Resident had verbal altercation with (Resident # 6) while in front of nursing station on 5/23/13; Care plan initiated 1/2/13 and revised (reviewed) 5/24/2013. Goals: ? Reduced incidents of agitated behaviors; initiated 1/2/13 and revised (reviewed) on 5/22/2013. ? Resident will have decrease episode of verbal altercation x 90 days; initiated 1/6/2013 and revised (reviewed) 5/22/2013 ? Resident will have less episode of verbal altercation with other resident x 90 day; initiated 5/24/2013 Interventions: ? Both residents were immediately remove in a different way on 5/7/13; initiated 5/9/2013 ? Both residents were immediately (removed) to different way on 1/4/13; initiated 1/6/2013 ? Both residents were separated in different direction on 3/15/13; initiated 3/18/13 ? Coordinate with social worker for plan of correction; initiated 1/2/13 ? Document on MDN (charting system) summary of each episode, any changed in mood/or mental status; initiated 1/2/2013 ? Elicit family input for best approached to resident on 3/15/13; initiated 3/18/13 ? Give medication as prescribed by MD; initiated 1/2/13 ? Psych consult 3/15/13; initiated 3/18/13 ? Psych consult for med review on 5/23/13; initiated 5/24/13 ? Psych consult to evaluate; initiated 5/9/13 ? Psych consult 1/4/13 ? Remove resident from public area when behavior is disruptive/unacceptable. Talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity; initiated 1/2/13 ? Resident was educated not to use inappropriate words while talking to staff/other residents on 5/23/13; initiated on 5/24/13 ? Two residents were separated in different way on 5/23/13; initiated 5/24/13 " A telephone interview was conducted on July 23, 2013 at 8:50 AM with Employee #1. He/She stated, " The family never wanted to have anything to do with (Resident #1). We received a letter from his/her mom that told us not to bother the family and that Resident #1 was his/her own responsible party. That ' s why we were petitioning for guardianship. " According to a social worker ' s note dated March 18, 2013 at 10:34 AM: " Verbal Altercation Note: ...SW interviewed (Resident #1) regarding this incident (breaking cord of Resident #3) and he/she denies doing anything to (Resident #3) cord to his/her wheelchair. SW reminded the resident to allow staff to intervene for him/her when verbal altercation occur in the future. (Resident #1) also agreed to locate to another floor when possible ... " According to a social worker ' s note dated May 8, 2013 at 1:45 PM: " Resident was interviewed regarding physical altercation regarding him/her and (Resident #4). Resident #1 said, " I was just talking to myself and he/she thought I was talking to him/her and he/she pushed my coffee out of my hand. " SW counseled the resident to allow staff to assist him/her if something like this happens again. (Resident #1) said ' alright. ' ... " According to a social worker ' s note dated May 23, 2013 at 5:46 PM: " Writer interviewed (Resident #1) regarding his/her threats towards (Resident #5). Resident #1 said, " I was just talking to myself and I was joking with him/her about shooting him/her with a gun. " Writer counseled (Resident #1) not to joke around with people like that or in a threatening way. (Resident #1) said, " o.k. ' Resident was relocated from (room to room) as an intervention ... " According to the social worker ' s note dated June 10, 2013 at 10:53 AM: " Resident was alleged to be having anal sex with (Resident #2). Even though feces was observed on (Resident #2 ' s) stomach, his diaper open and sweating excessively and (Resident #1) running from the roommate ' s bed to wipe himself off in the bathroom, (Resident #1) told this SW that " they think I did something to my roommate but I didn ' t do anything. " Police were already present and investigating the incident ... " A face-to-face interview was conducted with Employee # 4 on July 23, 2013 at 9:25 AM. He/she was asked about the above concerns and stated, " I would check-in with (Resident #1) every day. When he/she was talking to himself/herself I would encourage him/her to talk quietly, keep it down. I didn ' t do any verbal counseling other than what ' s in my notes. I didn ' t do any de-escalation methods. " According to a psychiatrist ' s note dated November 15, 2012: [AGE] year old homeless African American seen today for initial psychiatric evaluation. He/she came to (facility) less than a week ago with an alleged history of [MEDICAL CONDITION] Disease for which he/she was placed on [MEDICATION NAME] by patient. Claims he/she has been hearing voices, seeing things that no one can see. Claims he/she has been on [MEDICATION NAME] for down in the dumps with poor sleeping habits. (Has) History of uncontrolled Diabetes Mellitus for which is requesting his/her meds to be readjusted. He/she looks older than his/her stated age. Wheelchair bound asking for help with his/her mental and physical issues. Speech is coherent but loud. Mood and affect are labile. He/she is not a danger to self or to others at this time. Oriented x 3 with fair cognition. Valporic Acid level 51.0, AST/ALT - WNL, PLT=26. DX: [MEDICAL CONDITION] Disorder, [MEDICAL CONDITION]. Plan: 1. [MEDICATION NAME] level 51.0 Good 2. [MEDICATION NAME] 100 mg q HS for increased sleep 3. [MEDICATION NAME] SR 100 mg po daily for depression and mood swings 4. Next visit in 3 months " According to a psychiatrist ' s note dated December 27, 2012: " Talking to self - Rule out acute exacerbation of [MEDICAL CONDITION] despite recent [MEDICATION NAME] adjustments ... 1. Increase [MEDICATION NAME] to 50 mg po bid and continue with [MEDICATION NAME] 100 mg po q HS 2. Hold it if blood pressure < 90/60, falls or if over sedated. " According to a psychiatrist ' s note dated February 28, 2013: " Evaluate for Depression - patient has a long history of [MEDICAL CONDITION] Disease for which he/she was placed on [MEDICATION NAME] for mood swings. He/she seems to be the opposite lately. 1. Add [MEDICATION NAME] SR 100 mg po daily for depression 2. Next visit in 3 months " According to a psychiatrist ' s note dated March 21, 2013: " Had a verbal altercation with another resident. Rule out intermittent [MEDICAL CONDITION]. 1. Verbal counseling needed 2. De-escalation methods to apply 3. No need for psych meds now 4. Next visit PRN " According to a psychiatrist ' s note dated April 11, 2013: " Talking to self, unacceptable behavior - used his leg to hit charge nurse on buttocks while giving care to roommate. (Has) History of [MEDICAL CONDITION] Disorder for which he was placed on [MEDICATION NAME] and [MEDICATION NAME] but continues to be a behavior issue as per recent incident. Recent Valporic level 51.0 okay. 1. Increase [MEDICATION NAME] to 750 mg po bid for mood swings and blood level in 2 weeks 2. Add [MEDICATION NAME] 50 mg po q AM for agitated behaviors 3. Continue to redirect as needed 4. Next visit in 90 days. " According to a psychiatrist ' s note dated May 30, 2013: " Inappropriate behavior holding his/her private part in the hallway, resident had verbal altercation with another resident. Rule out Paraphilliac behaviors, rule out indecent exposure, and rule out impulse control 1. Increase [MEDICATION NAME] SR to 200 mg po daily for depression and impulsivity 2. Stop [MEDICATION NAME] orders 3. Resume [MEDICATION NAME] 100 mg po every 8 hours for agitated behaviors. 4. Hold #3 if BP < 90/60, falls/sedation and call the writer 5. Next visit in 90 days/PRN. " A review of the November and December 2012 and January through August, 2013 Medication Administration Records revealed that the resident received all the above cited prescribed medications There was no explanation or evidence of " de-escalation methods " as documented in the above cited psychiatrist ' s note dated March 21, 2013. Resident #2 was born on July 13, 1953 and was admitted to the facility on [DATE]. According to the Minimum Data Set assessment dated [DATE], Resident #2 was assessed with [REDACTED]. Resident #2 was assessed as requiring extensive assistance for bed mobility, eating, and totally dependent for transfers, dressing, toilet use, personal hygiene and bathing in Section G. Disease [DIAGNOSES REDACTED]. June 7, 2013 at 7:00 AM: " Resident alert at 12:45 AM when one of the assigned caregiver ' s went to check on him, saw the roommate (Resident #1) run out of his/her bedside into the bathroom and start using toilet water to wash his/her perineal area. The writer went in the room and the resident ' s diaper was open and feces were all over the resident, his/her bedding and everywhere. Resident was asked what happened. He/she was unable to explain nothing. He/she was assessed with [REDACTED]. Bedding was saved for evidence. Resident was cleaned up. PMD made aware. Gave order to monitor resident closely and place roommate on 1:1 care. Unable to reach R/P at this time. Several calls made but line busy. At 6 AM resident was reassessed and his anal area was widely opened. 911 and police called to the unit by Clinical Manager. " June 7, 2013 at 7:30 AM: " At 6:05 AM police and ambulance arrived at the unit.(Police Officers) were given report and answers were provided accordingly. At 7:17 AM (Resident #2) was transferred to (hospital) for proper evaluation. Change of status done. Still unable to reach R/P at this time. Report will be given to on-coming shift to follow up with R/P. " According to www.dccourts.gov <http://www.dccourts.gov> the following was revealed regarding Resident #1: " Felony I File date: June 8, 2013 Status: pending Sentencing Status date: 6/8/13 Disposition: Guilty - Plea Judgment Guilty Disposition Date: 7/8/2013 June 8, 2013 charged with second degree sex abuse - incompetent June 21, 2013 Event resulted - release status NO BOND defense oral request to continue this matter to explore government ' s plea offer with her client; 90 and 100 day time is tolled for this interval, come up issued. July 8, 2013 the charge was disposed and a plea judgment of guilty September 17, 2013 9:30 AM full report and sentencing July 8, 2013 Plea Offer filed July 8, 2013 Information of Indictment Filed Charge #1: Second Degree Sex Abuse - Incompetent ... " Resident #1 was transferred three (3) times and had four (4) different roommates from November 18, 2012 until June 6, 2013. Three (3) roommates were capable of making their needs known and requiring minimal supervision in walking or using a wheel chair to move throughout the facility. Resident #2 was the fourth roommate and unable to make his/her needs known and totally dependent on staff for all of his/her needs. Facility staff failed to protect Resident #2 from sexual abuse from Resident #1. The record was reviewed June 11, 2013.

Based on record review and staff interview for one (1) resident, it was determined that facility staff failed to supervise Resident #1 who subsequently sexually abused Resident #2. The findings include: Resident #1 was born on January 23, 1973 and was admitted to the facility on [DATE]. According to the Minimum Data Assessment (MDS) dated [DATE], Resident #1 achieved a score of 15/15 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 " 13-15 " suggests that the resident is " cognitively intact. " Resident #1 was assessed as being independent for walking; requiring supervision for bed mobility, transfers, dressing, eating, toilet use; and extensive assistance for bathing in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. The following nurses ' notes were reviewed for Resident #1: March 11, 2013 at 2:00 AM: " Upon round making this writer found Resident #1 naked without wearing anything on and was standing in the room close to the door. This writer asked him/her to put on something to cover him/herself, a gown was provided he/she threw it on the floor and another one was given and he/she took it and started doing like have illusions/delusions symptoms. He/she later laid down in bed and remained on his bed. " March 18, 2013 at 10:34 AM: " Resident #1 and Resident #3 had a verbal altercation regarding the cord to Resident #3 ' s charger for his/her wheelchair being broken. Resident #3 angrily accused Resident #1 of breaking the cord to the wheelchair ' s charger. SW interviewed Resident #1 regarding this incident and he/she denies doing anything to Resident #3 ' s cord to his/her wheelchair charger. SW reminded the resident to allow staff to intervene for him/her when verbal altercation occurs in the future. Resident #1 also agrees to relocate to another floor when possible. Clinical manager is aware of this incident and an incident report was generated. " March 24, 2013 at 5:00 AM: " Resident #1 is alert and very responsive resident. Roommate called this writer while he/she was attending to the (roommate) that he/she feels tired and funny. This writer went to the (roommate) in room to check his/her blood sugar and see if he/she is okay. Resident #1 saw this writer when he/she came over to (roommate) because he/she pulled his/her overhead light on and quickly turn it off while this writer was checking (roommate ' s) blood sugar. Resident #1 used his/her leg to hit this writer in his/her buttocks and started laughing. When the nurse asked why he/she did that Resident#1 stated because " I am retarded and you are also. " This writer redirected Resident #1 (who) started talking and yelling to him/herself as if he/she is hearing voices PMD and R/P left messages for. " March 24, 2013 at 6:15 AM: " Supervisor on the unit at this time went to the Resident #3 and asked him/her why he/she used his/her leg to hit the writer ' s buttocks and he/she apologized that he/she did not do it intentionally. " May 7, 2013 at 9:30 PM: " Resident #1 is alert and verbally responsive. Received a call from the supervisor that the resident is saying FU ... word then Resident #4 pushed Resident #1 ' s hand with a cup of coffee and spilled it on Resident #1 ' s hand and cup dropped on the floor. On assessment no burns, injury on Resident #1 ' s hand and denies pain. MD made aware. RP notified. Resident #1 kept calm and safe. Stable at this time V/S (vital signs) BP (Blood Pressure) 122/76, R (Respirations) 18, P (Pulse) 78, T (Temperature) 97.8? " May 8, 2013 at 1:45 PM: " Resident #1 was interviewed (by Social Worker) regarding the physical altercation between him/her and Resident #4. Resident #1 said " I was just talking to myself and he/she thought I was talking to him/her and he/she pushed my coffee out of my hand. " SW counseled the resident to allow staff to assist him/her if something like this happens again. He/she said " alright " ADON is aware of the incident and an incident report will be generated. " May 10, 2013 at 2:00 PM: " Resident #1 is alert and responsive. Signed out self at 1:30 PM. " May 10, 2013 at 11:00 PM: " Resident #1 remains out on pass (OOP) Resident signed self out at 1:30 PM - morning shift going to (address). (Mother) made aware (Resident #1) is OOP. RP made aware by leaving a message that she signed a paper giving (Resident #1) authority to go out of (Facility) and to return. RP made aware by leaving a message that member of customer service working in this facility saw (Resident #1 at an address) in between (Street) and the shoe repair center drinking and smoking and does not want to come home to the facility yet. Supervisor made aware. In-coming shift please follow up. " May 11, 2013 at 2:40 PM: " At 1:40 AM Resident #1 returned to the unit from OOP he/she came in by him/herself and refused to be assessed. Also refused V/S to be taken on him/her. He/she was very agitated and loud and PMD made aware. He/she gave telephone order to transfer resident to the nearest ER for proper evaluation 911 activated at 2 AM resident was transferred to (hospital) as ordered. Resident #1 acknowledged that he/she had some " liquor " in the street ... " May 11, 2013 at 2:00 PM: " Resident #1 alert and verbally responsive returned to the unit from (hospital) at 1:00 PM. BP 130/70, T - 98.7, R- 20, P 80 ... " May 23, 2013 at 2:30 PM: " Resident #5 was in the bathroom. Resident #1 went to the bathroom following Resident #5 to the bathroom. Resident #5 said he/she is being threatened by Resident #1 (who) said that he/she will shot him/her with his/her gun. Resident #5 called the police. (Police Officer) of District 7, responded and came in the unit. Interviewed Resident #1. Police officer asked Resident #1 where is your gun. Resident #1 answered it ' s here pointing to his/her private part. Police officer spoke to Resident #5 and explained that Resident #1 has no gun and he/she is only joking about it. Resident #5 felt relief both residents stable. R/P notified. " May 23, 2013 at 3:30 PM: " Resident#1 had verbal altercation with Resident #6 at the nurse station. There is no physical contact. Both residents were separated to their rooms. R/P notified by message. MD notified. Resident #1 stable. " June 6, 2013 at 11:00 PM: " Resident room changed from (room number) to (room number) due to incompatibility of roommate. R/P notified. PMD made aware ... " June 7, 2013 at 2:00 AM: " Resident #1 alert and very responsive during shift change rounds. Writer noted this resident put the heater to 95?. He/she was instructed to lower it down since it ' s too hot and his roommate was sweating excessively. Request a CNA to monitor him q 15 min. At 12:45 AM the CNA went to the room, knocked at the door and opened it. Noted that resident ran from roommate (Resident #2) side of the room to bathroom and started using toilet water to clean him/herself. This writer went to the room; roommate ' s (Resident #2) diaper was opened. Feces were all over roommate ' s body and his bedding. Resident #1 was also assessed and had feces from stomach area to the perianal area. Writer asked Resident #1 what he/she was doing. Resident #1 said washing and became loud. PMD made aware and gave telephone order to place Resident #1 on 1:1 care until tomorrow. PMD will call the facility. R/P made aware. Resident #1 refused vital signs. " June 7, 2013 at 8:00 AM: " Resident #1 alert. At 6:05 AM police and ambulance on the unit based on fact that during the second round of assessment his roommate ' s (Resident #2) anal area was widely opened. At this time, Resident #1 is still resting quietly. " June 7, 2013 at 10:00 AM: Resident #1 alert and very responsive. He/she was taken out of the unit by the Department of Police for interrogation at sexual crime unit downtown DC. R/P message left. Expecting her call back and change of status done. PMD made aware. " Resident #7 was the roommate to Resident #1 from November 9, 2012 (Resident #1 ' s admission) until November 23, 2012. Resident #7 was born on June 1, 1944 and was admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment completed October 2, 2012, Resident #7 achieved a score of 12/15 on the Brief Interview for Mental Status (BIMS) in Section C (Cognitive Patterns). According to the " MDS 3.0 User ' s Manuel " page C-14, a score of " 8-12 " suggests that the resident is " mildly cognitively impaired. " Resident #7 was assessed as being independent with bed mobility, transfers, walking, eating and toileting and required supervision for dressing and personal hygiene and totally dependent for bathing and used a wheelchair for mobility in Section G (Functional Status). Disease [DIAGNOSES REDACTED]. On November 18, 2012, Resident #1 complained that Resident #7 hit him/her on the face three (3) times. Resident #1 was relocated to (first room available) on November 23, 2012 and his/her roommate was Resident #5. Resident #5 was the roommate to Resident #1 when they resided in (room) from November 23, 2012 until May 23, 2013. Resident #5 was born on February 19, 1949 and was admitted to the facility on [DATE]. According to the MDS assessment dated [DATE], Resident #5 achieved a score scored of 15/15 on the BIMS in Section C. According to the " MDS 3.0 User ' s Manuel " page C-14, a score of " 13-15 " suggests that the resident is " cognitively intact. " Resident #5 was assessed as being independent for eating; requiring supervision for bed mobility, transfers, eating, and toilet use; limited assistance for dressing; extensive assistance for personal hygiene and totally dependent for bathing and used a wheelchair for mobility in Section G. Disease [DIAGNOSES REDACTED]. According to a nurse ' s note dated May 23, 2013 at 2:30 PM: " Resident #5 was in the bathroom. Resident #1 went to the bathroom following Resident #5 to the bathroom. Resident #5 said the he/she is being threatened by Resident #5 (who) said that he/she will shot him/her with his/her gun. Resident #5 called the police. (Police Officer) of District 7, responded and came in the unit. Interviewed Resident #1. Police officer asked Resident #1 where is your gun. Resident #1 answered it ' s here pointing to his/her private part. Police officer spoke to Resident #5 and explained that Resident #1 has no gun and he/she is only joking about it. Resident #5 felt relief both residents stable. R/P notified. " On May 23, 2013, Resident #1 was transferred from (room to room) and his/her roommate was Resident #8 Resident #8 became the roommate when he/she entered the facility on May 23, 2013 until June 6, 2013. Resident #8 was born on November 19, 1937. According to the admission MDS, Resident #8 achieved a score of 15/15 on the BIMS in Section C. Resident #8 was assessed as being independent for eating, requiring supervision with walking in the room, extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and totally dependent for bathing in Section G. Disease [DIAGNOSES REDACTED]., and Acute Kidney Failure. A telephone interview was conducted with Employee #1 on July 17, 2013 at 11:30 AM. He/she was asked about the above cited relocation and stated, " Resident #8 told me that Resident #1 played his/her music too loudly and that he/she was always talking to him/herself. So we moved Resident #1 to (room). " On June 6, 2013, Resident #1 was transferred to (room) and his roommate was Resident #2. Resident #2 was the roommate on June 6, 2013. He/she was born on July 13, 1953 and was admitted to the facility on [DATE]. According to the Minimum Data Set assessment dated [DATE], Resident #2 was assessed with [REDACTED]. Resident #2 was assessed as requiring extensive assistance for bed mobility, eating, and totally dependent for transfers, dressing, toilet use, personal hygiene and bathing in Section G. Disease [DIAGNOSES REDACTED]. Observation of Resident #2 was conducted on June 11, 2013 at 10:15 AM. Resident #2 was observed in a geri-chair in the day room. Resident #2 was asked if anyone had hurt or harmed him. Resident #2 responded in a soft voice and mumbled incoherently. Resident #2 had contractures of bilateral arms and bilateral legs. According to a nurse ' s noted dated June 7, 2013 at 7:00 AM: " Resident #2 alert at 12:45 AM when one of the assigned caregiver ' s went to check on him/her, saw the roommate (Resident #1) run out of his/her bedside into the bathroom and start using toilet water to wash his/her perineal area. The writer went in the room and the Resident #2 ' s diaper was open and feces were all over the resident, the bedding and everywhere. Resident #2 was asked what happened. He/she was unable to explain nothing. Resident #2 was assessed with [REDACTED]. Bedding was saved for evidence. Resident #2 was cleaned up. PMD made aware. Gave order to monitor resident closely and place roommate on 1:1 care. Unable to reach R/P at this time. Several calls made but line busy. At 6 AM resident was reassessed and his anal area was widely opened. 911 and police called to the unit by Clinical Manager. " June 7, 2013 at 7:30 AM: " At 6:05 AM police and ambulance arrived at the unit. Officers (badge numbers) were given report and answers were provided accordingly. At 7:17 AM resident was transferred to (hospital)for proper evaluation. Change of status done. Still unable to reach R/P at this time. Report will be given to on-coming shift to follow up with R/P. " A face-to-face interview was conducted with Employee #3 on June 11, 2013 at 5:00 AM. He/she was asked about the above concerns and stated, " The CNAs put Resident #2 in the geri-chair so we could clean up his/her bed and we took him/her to the nursing station. Resident #1 was placed one-to-one for the rest of the shift. " According to Resident #1 ' s Care Plan, the following problems were noted: " Focus: problematic manner in which resident acts characterized by inappropriate sexual behavior (Verbal and physical) related to: resident touches other residents and/or staff inappropriately. Resident used his leg and hit charge nurse on buttocks 3/24/13. Resident said to roommate that he/she will shoot him/her with a gun. When asked where is the gun, he/she pointed to his/her private parts. 6/7/13 Resident ran out from his/her roommate ' s side with feces all over him/her to the bathroom using toilet water to clean him/herself and with feces from his/her stomach to perineal area. " Care plan problem was initiated on March 25, 2013 and revised (updated) on May 24, 2013 and June 7, 2013. " Goals: (1) Reduce incidents of inappropriate sexual behaviors; initiated on March 25, 2013 and revised (reviewed) March 25, 2013. (2) Resident will carry out sexual behavior with self only in privacy of own room; initiated on May 24, 2013. Interventions: ? Distract resident if possible; initiated 3/25/ 2013 ? Document a summary of each episode; initiated on 3/25/ 2013 ? Police was called in the building 5/23/13; initiated 5/24/ 2013 ? Psych consult; initiated 3/25/ 2013 ? Remove resident from public area when behavior is disruptive/unacceptable. Talk with resident in low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity; initiated 3/25/2013 ? Resident relocated to different room 5/23/13; initiated 5/24/2013 ? Set limits for acceptable behavior; Care plan initiated 3/25/2013 "Focus: Problematic manner in which resident acts characterized by ineffective coping; agitation related to: Anxiety resident had verbal altercation with other resident in the hallway on 1/4/13. Resident had a verbal altercation with another (Resident #3) on 3/15/13. Resident had verbal altercation with another (Resident #4 on May 7, 2013). Resident had verbal altercation with (Resident # 6) while in front of nursing station on 5/23/13; Care plan initiated 1/2/13 and revised (reviewed) 5/24/2013. Goals: ? Reduced incidents of agitated behaviors; initiated 1/2/13 and revised (reviewed) on 5/22/2013. ? Resident will have decrease episode of verbal altercation x 90 days; initiated 1/6/2013 and revised (reviewed) 5/22/2013 ? Resident will have less episode of verbal altercation with other resident x 90 day; initiated 5/24/2013 Interventions: ? Both residents were immediately remove in a different way on 5/7/13; initiated 5/9/2013 ? Both residents were immediately (removed) to different way on 1/4/13; initiated 1/6/2013 ? Both residents were separated in different direction on 3/15/13; initiated 3/18/13 ? Coordinate with social worker for plan of correction; initiated 1/2/13 ? Document on MDN (charting system) summary of each episode, any changed in mood/or mental status; initiated 1/2/2013 ? Elicit family input for best approached to resident on 3/15/13; initiated 3/18/13 ? Give medication as prescribed by MD; initiated 1/2/13 ? Psych consult 3/15/13; initiated 3/18/13 ? Psych consult for med review on 5/23/13; initiated 5/24/13 ? Psych consult to evaluate; initiated 5/9/13 ? Psych consult 1/4/13 ? Remove resident from public area when behavior is disruptive/unacceptable. Talk with resident in a low pitch, calm voice to decrease/eliminate undesired behavior and provide diversional activity; initiated 1/2/13 ? Resident was educated not to use inappropriate words while talking to staff/other residents on 5/23/13; initiated on 5/24/13 ? Two residents were separated in different way on 5/23/13; initiated 5/24/13 " A telephone interview was conducted on July 23, 2013 at 8:50 AM with Employee #1. He/She stated, " The family never wanted to have anything to do with (Resident #1). We received a letter from his/her mom that told us not to bother the family and that Resident #1 was his/her own responsible party. That ' s why we were petitioning for guardianship. " According to a social worker ' s note dated March 18, 2013 at 10:34 AM: " Verbal Altercation Note: ...SW interviewed (Resident #1) regarding this incident (breaking cord of Resident #3) and he/she denies doing anything to (Resident #3) cord to his/her wheelchair. SW reminded the resident to allow staff to intervene for him/her when verbal altercation occur in the future. (Resident #1) also agreed to locate to another floor when possible ... " According to a social worker ' s note dated May 8, 2013 at 1:45 PM: " Resident was interviewed regarding physical altercation regarding him/her and (Resident #4). Resident #1 said, " I was just talking to myself and he/she thought I was talking to him/her and he/she pushed my coffee out of my hand. " SW counseled the resident to allow staff to assist him/her if something like this happens again. (Resident #1) said ' alright. ' ... " According to a social worker ' s note dated May 23, 2013 at 5:46 PM: " Writer interviewed (Resident #1) regarding his/her threats towards (Resident #5). Resident #1 said, " I was just talking to myself and I was joking with him/her about shooting him/her with a gun. " Writer counseled (Resident #1) not to joke around with people like that or in a threatening way. (Resident #1) said, " o.k. ' Resident was relocated from (room to room) as an intervention ... " According to the social worker ' s note dated June 10, 2013 at 10:53 AM: " Resident was alleged to be having anal sex with (Resident #2). Even though feces was observed on (Resident #2 ' s) stomach, his diaper open and sweating excessively and (Resident #1) running from the roommate ' s bed to wipe himself off in the bathroom, (Resident #1) told this SW that " they think I did something to my roommate but I didn ' t do anything. " Police were already present and investigating the incident ... " A face-to-face interview was conducted with Employee #4 on July 23, 2013 at 9:25 AM. He/she was asked about the above concerns and stated, " I would check-in with (Resident #1) every day. When he/she was talking to himself/herself I would encourage him/her to talk quietly, keep it down. I didn ' t do any verbal counseling other than what ' s in my notes. I didn ' t do any de-escalation methods. " According to a psychiatrist ' s note dated November 15, 2012: [AGE] year old homeless African American seen today for initial psychiatric evaluation. He/she came to (facility) less than a week ago with an alleged history of BiPolar Disease for which he/she was placed on Depakote by patient. Claims he/she has been hearing voices, seeing things that no one can see. Claims he/she has been on Depakote for down in the dumps with poor sleeping habits. (Has) History of uncontrolled Diabetes Mellitus for which is requesting his/her meds to be readjusted. He/she looks older than his/her stated age. Wheelchair bound asking for help with his/her mental and physical issues. Speech is coherent but loud. Mood and affect are labile. He/she is not a danger to self or to others at this time. Oriented x 3 with fair cognition. Valporic Acid level 51.0, AST/ALT - WNL, PLT=26. DX: Schizoaffective Disorder, BiPolar. Plan: 1. Depakote level 51.0 Good 2. Seroquel 100 mg q HS for increased sleep 3. Bupropion SR 100 mg po daily for depression and mood swings 4. Next visit in 3 months " According to a psychiatrist ' s note dated December 27, 2012: " Talking to self - Rule out acute exacerbation of psychotic disorder despite recent Seroquel adjustments ... 1. Increase Seroquel to 50 mg po bid and continue with Seroquel 100 mg po q HS 2. Hold it if blood pressure < 90/60, falls or if over sedated. " According to a psychiatrist ' s note dated February 28, 2013: Evaluate for Depression - patient has a long history of BiPolar Disease for which he/she was placed on Seroquel for mood swings. He/she seems to be the opposite lately. 1. Add Bupropion SR 100 mg po daily for depression 2. Next visit in 3 months " According to a psychiatrist ' s note dated March 21, 2013: " Had a verbal altercation with another resident. Rule out intermittent explosive disorder. 1. Verbal counseling needed 2. De-escalation methods to apply 3. No need for psych meds now 4. Next visit PRN " According to a psychiatrist ' s note dated April 11, 2013: " Talking to self, unacceptable behavior - used his leg to hit charge nurse on buttocks while giving care to roommate. (Has) History of BiPolar Disorder for which he was placed on Depakote and Seroquel but continues to be a behavior issue as per recent incident. Recent Valporic level 51.0 okay. 1. Increase Depakote to 750 mg po bid for mood swings and blood level in 2 weeks 2. Add Seroquel 50 mg po q AM for agitated behaviors 3. Continue to redirect as needed 4. Next visit in 90 days. " According to a psychiatrist ' s note dated May 30, 2013: " Inappropriate behavior holding his/her private part in the hallway, resident had verbal altercation with another resident. Rule out Paraphilliac behaviors, rule out indecent exposure, and rule out impulse control 1. Increase Bupropion SR to 200 mg po daily for depression and impulsivity 2. Stop Seroquel orders 3. Resume Seroquel 100 mg po every 8 hours for agitated behaviors. 4. Hold #3 if BP < 90/60, falls/sedation and call the writer 5. Next visit in 90 days/PRN. " A review of the November and December 2012 and January through August, 2013 Medication Administration Records revealed that the resident received all the above cited prescribed medications There was no explanation or evidence of " de-escalation methods " as documented in the above cited psychiatrist ' s note dated March 21, 2013. Resident #2 was born on July 13, 1953 and was admitted to the facility on [DATE]. According to the Minimum Data Set assessment dated [DATE], Resident #2 was assessed with [REDACTED]. Resident #2 was assessed as requiring extensive assistance for bed mobility, eating, and totally dependent for transfers, dressing, toilet use, personal hygiene and bathing in Section G. Disease [DIAGNOSES REDACTED]. June 7, 2013 at 7:00 AM: " Resident alert at 12:45 AM when one of the assigned caregiver ' s went to check on him, saw the roommate (Resident #1) run out of his/her bedside into the bathroom and start using toilet water to wash his/her perineal area. The writer went in the room and the resident ' s diaper was open and feces were all over the resident, his/her bedding and everywhere. Resident was asked what happened. He/she was unable to explain nothing. He/she was assessed with [REDACTED]. Bedding was saved for evidence. Resident was cleaned up. PMD made aware. Gave order to monitor resident closely and place roommate on 1:1 care. Unable to reach R/P at this time. Several calls made but line busy. At 6 AM resident was reassessed and his anal area was widely opened. 911 and police called to the unit by Clinical Manager. " June 7, 2013 at 7:30 AM: " At 6:05 AM police and ambulance arrived at the unit.(Police Officers) were given report and answers were provided accordingly. At 7:17 AM (Resident #2) was transferred to (hospital) for proper evaluation. Change of status done. Still unable to reach R/P at this time. Report will be given to on-coming shift to follow up with R/P. " According to www.dccourts.gov <http://www.dccourts.gov> the following was revealed regarding Resident #1: " Felony I File date: June 8, 2013 Status: pending Sentencing Status date: 6/8/13 Disposition: Guilty - Plea Judgment Guilty Disposition Date: 7/8/2013 June 8, 2013 charged with second degree sex abuse - incompetent June 21, 2013 Event resulted - release status NO BOND defense oral request to continue this matter to explore government ' s plea offer with her client; 90 and 100 day time is tolled for this interval, come up issued. July 8, 2013 the charge was disposed and a plea judgment of guilty September 17, 2013 9:30 AM full report and sentencing July 8, 2013 Plea Offer filed July 8, 2013 Information of Indictment Filed Charge #1: Second Degree Sex Abuse - Incompetent ... " Resident #1 was transferred three (3) times and had four (4) different roommates from November 18, 2012 until June 6, 2013. Three (3) roommates were capable of making their needs known and requiring minimal supervision in walking or using a wheel chair to move throughout the facility. Resident #2 was the fourth roommate and unable to make his/her needs known and totally dependent on staff for all of his/her needs. Facility staff failed to protect Resident #2 from sexual abuse from Resident #1. The record was reviewed June 11, 2013.

Based on observation, staff interview and record review for three (3) of 87 sampled residents, it was determined that facility staff failed to ensure that a resident with a history of having pressure sores receives necessary treatment and services to promote healing as evidenced by failure to accurately and/or consistently assess the resident's skin integrity on " Weekly Wound Progress Report " forms for Residents #236, #43 and #178. The findings include: 1. Facility staff failed to consistently evaluate the pressure area to Resident #236's left ischium wound to ensure that appropriate interventions/necessary treatment and services were provided to promote wound healing. According to Resident #236's annual Minimum Data Set, dated dated dated [DATE], the resident was coded as having [MEDICAL CONDITION] in both eyes and Paraplegic under Section I (Diagnoses). In Section M0150 (Risk of Pressure Ulcers) the resident was coded as " yes"=indicating that he/she was at risk for developing a pressure ulcer. According to the Braden scale dated September 4, 2012 the resident was total score was " 15 " = low risk for developing a pressure ulcer. An observation was conducted on October 22, 2012 at 9:13 AM of Resident #236's room. It was observed that an air mattress was on the resident's bed and the wheelchair used by the resident had padding on the seat, and positioning equipment was in the bed with the resident. A review of the physician's order [REDACTED]. September 19, 2012 directed, " Cleanse left ischium with NS (normal saline) and apply [MEDICATION NAME], cover with 4x4 gauze. " October 10, 2012 (no time indicated) directed, " Apply Santyl and cover with 4x4 adhesive gauze daily. " The September 2012 " Treatment Administration Record " revealed that the Resident received [MEDICATION NAME] to left Ischium from September 19-30, 2012. On September 26 and 28, 2012 it was noted that the resident refused to have his/her treatment done. The October 2012 " Treatment Administration Record " , revealed that from October 11 - 21, 2012 the resident received Santyl ointment treatment to his/her left ischium. It was noted that the resident refused his/her treatment on October 3, 2012. The " Team Notes " dated September 25, 26, 27, 28, 29, 30, and October 3, 2012 revealed that the resident refused for his/her dressing to be changed and on October 8, 2012 the facility held a meeting with the resident to discuss realistic resolutions regarding (the resident ' s) refusal to accept services/tx (treatment) from a midnight nurse. The care plans updated September 8, October 18 and 22, 2012 revealed that there was no care plan implemented with descriptive interventions to address the resident ' s non-compliance with receiving treatment to his/her left ischium. A review of the Doctors Progress notes revealed: August 28, 2012 Wound Rounds: The R (right) and L (left) ischium are both intact with pink scar tissue. The sacrum is 100% pale granulation wit surrounding scar tissue and no drainage. Pt (Patient) on air mattress and has a gel w/c (wheelchair) cushion. The heels are intact. Continue Hydrogel as ordered. Call MD (medical doctor) with any concerns. September 4, 2012 Wound Rounds: " The sacrum and both ischiums are closed with scar tissue and there was no opening. Pt was encouraged to do w/c lifts and has an air mattress, continue prevention measures call MD with any concerns ... " October 16, 2012 Wound Rounds: The left ischium is covered with about 50 % yellow/black slough and 50% red clean granulation and moderate drainage with no odor. There was no surrounding induration. The patient has no sensation; thereby (he/she) has no pain ... Pt is non-compliant with staying out of the chair and going back to bed. (He/she) did agree to going back to bed, but then doesn ' t do what is asked. Pt has an air mattress and a gel w/c pad ... " The " Weekly Wound Progress Report " revealed: ? Date of onset, September 19, 2012, Wound Type: Pressure; Site: Left Ischium; Stage/Thickness: Stage II, L (length) 2cm, W(width) 2cm, D (Depth) 0 (wound) status/treatment orders-no change; Order Changed: no " ? September 24, 2012, Wound Type: Pressure; Site: Left Ischium; Stage/Thickness: Stage II; L (length): 2cm, W (width): 2cm, D (depth): blank (no assessment documented); Wound bed: 100% granulation; Impression of (wound) status/treatment orders= No change, Order Changed: No " ? There was no Weekly Wound Progress Report for the week of October 1, 2012. ? October 8, 2012, Wound Type: Pressure; Site: Left Ischium; Stage/Thickness: was left blank (not indicating any stage of the wound); L (length): 2cm, W (width): 2cm, D (depth): 0; Wound bed: was left blank, not indicating the characteristics of the wound bed; Impression of (wound) status/treatment orders=this area was left blank not indicating if the wound improved, no change or deteriorated; or if the order had changed. Note: Facility staff failed to identify the pressure sore stage, depth, wound bed, and status. ? October 10, 2012, Wound Type: Pressure; Site: Left Ischium; Stage/Thickness: Stage III; L (length): 6cm, W (width): 3.5cm, D (depth): 0; Wound bed: 40% granulation and 60% yellow slough; Drainage amount=scant; Drainage color/type Serous, no odor; Impression of (wound) status/treatment orders=No changed=yes (treatment was changed to Santyl dressing daily). ? October 15, 2012, Wound Type: Pressure; Site: Left Ischium; Stage/Thickness: Stage III; L =6cm, W= 4cm, D=2cm; Wound bed: 40% granulation and 70% yellow slough; Drainage amount=scant; Drainage color/type Serous, no odor; Impression of (wound) status/treatment orders=No changed=No. A face-to-face interview was conducted with Employee #5 on October 22, 2012 at approximately 1:00 PM. Employee #5 was queried as to why the wound was measured on October 8 and 10, 2012. He/she stated, " We (facility staff) measured the wound on October 8, 2012. " At this time Employee #5 offered no further explanation for the measurement records on October 8 and 10, 2012. A face-to-face interview was conducted with the Employee #12 (wound consultant) on October 23, 2012 at 10:10 AM. Employee #12 queried as to why he/she did not include measurements in the "wound consult" notes. He/she stated, " I usually don't measure the wound if it has already been measured. I just describe the wound. I go by the progress report that the facility has already prepared. They had already staged it (the wound) to me it was unstageable. " A follow up interview was conducted with the Employees # 2, #4, and #5 on November 16, 2012 at approximately 10:40 AM. They reviewed the " Weekly Wound Progress Report " . When queried as to the lack of documentation depicting the characteristics of the wound on October 8, 2012, Employee #4 stated, " The process is the wound measurements are done on Mondays. If the nurse thinks that he/she is not satisfied with the way the wound looks. The manager will go back and re-qualify the wound. On Wednesday, October 10, 2012 the clinical manager was reviewing the wound progress note. He/she decided to re-qualify the wound. Although the documentation is not correct the right treatment was done. " Employee #5 was queried about the identified stage/thickness of the wound and the description of the wound bed on October 10, 2012. He/she stated, " The 40% granulation was the around the edges of the wound. The 60% yellow slough was in the wound bed. I could not see the wound bed. The wound was unstageable. " There was no evidence that facility staff evaluated Resident #236 ' s wound from September 25 to October 8, 2012. On October 8, 2012 the " Weekly Wound Progress " note lacked a stage/thickness of the wound, depth of the wound, no characteristic of the wound bed, and no impression of the wound status/treatment orders. Two (2) days later (October 10, 2012) the wound was Staged as a III (progressed from a Stage II to Stage III (September 24, 2012 to October 10, 2012)). In addition the size increased from 2x2x0 (cm) to 6x3.5x0 (cm), the wound bed had 40% granulation and 60% slough, scant drainage was observed and the impression of the wound was classified as " No change " and the treatment order was changed to Santyl (is active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level). Through interview with the facility staff it was stated that on October 8, 2012 if the nurse thinks that he/she is not satisfied with the way the wound looks. The manager will go back and re-qualify the wound, which was done two (2) days later when the wound (through interview) should have been classified as unstageable. Ultimately a change in the treatment was also delayed for two (2) days. Through observation and record review the resident had an air mattress applied to the bed and a gel cushion in his/her wheelchair. There was no evidence that while the resident refused several treatments/services there was no evidence that the care plan was updated to address the resident non-compliant behavior(s). There was no evidence the facility staff ensured that Resident #236, who had an alteration in skin integrity to the left ischium, was consistently evaluated to ensure that he/she received the necessary treatment and services to promote wound healing. The wound progressed over approximately 15 days from a stage II ulcer to an unstageable ulcer. The record was reviewed on October 22, 2012. 2. Facility staff failed to reassess and reevaluate the wound management/treatment plan when Resident #43 ' s sacral pressure ulcer failed to improve and was assessed as deteriorated on October 8, 2012. An " Interim Order Form " dated October 4, 2012 directed: " Cleanse wound with (Normal Saline); Pat dry, apply Hydrogel and cover with 4 X 4 Gauze Adhesive daily until healed. " According to a " Team Note " dated October 4, 2012 revealed; " Focus: Blister that (Broke) " : During Resident care, it was observed that resident has a blister that (broke); Length-2.5 cm, Width- 1cm on the right sacral area." The facility's " Weekly Wound Progress Reports " revealed Resident #43 ' s sacral ulcer deteriorated between the period of October 4 -8, 2012 as follows: October 4, 2012 - Wound Type: Pressure; Site : Right Lower Sacrum; - Stage II; Length: 2.5 cm; Width- 1 cm, Depth- 0; Tunneling: None; Wound bed- 100% granulation. October 8, 2012 - Stage II; Size: Length: 9.7 cm; Width- 4 cm; Depth- 0; Tunneling- none; Wound bed: 10% granulation; 90% eschar. " There was no evidence that the wound treatment regimen was modified to address the changes assessed in the status of the wound. According to a " Wound Rounds " note dated October 9, 2012 " The (patient) has an 80% slough covered wound with surrounding pale red edges; the wound has a scant amount of (sero-sangious) drainage. There was no induration and no odor. The wound was redressed. (Medical Doctor) called and family was called. (Patient) on an air mattress; overall condition is poor. Call MD with (any) concerns." A review of the clinical record lacked evidenced that facility staff reassessed and reevaluated the wound management treatment plan for Resident #43 after the pressure ulcer worsened on October 8, 2012. A face-to-face interview was conducted with Employee #10 on October 25, 2012 at approximately 3:00 PM regarding the aforementioned findings. He/she stated, " The treatment should have been changed. We called the wound nurse when the wound was not progressing; the wound nurse was called. He/she stated the resident ' s overall prognosis was poor; and hospice was going to be consulting on him/her. The wound treatment was not change. He/she also called the medical doctor and informed him/her. " The clinical record was reviewed on October 25, 2012. 3. Facility staff failed to implement appropriate interventions to promote healing for Resident #178 with a right lateral ankle wound. The wound was initially identified as a Stage III. The " Braden Scale " last updated August 25, 2012 revealed that the resident ' s total score was a"10", indicating that he/she was a "high risk" for acquiring pressure sore. The care plan entitled, " The resident is at risk for skin breakdown " initiated August 10, 2012 and last updated September 9, 2012 revealed, Focus-Impaired mobility, Incontinence ...; Interventions: Pressure redistribution surfaces to the bed ...Weekly skin assessment ...apply bunny boots at all times, assess skin condition as with ADL care daily and report abnormalities ...Pillow in between resident knees at all times ...place pillow between legs ... " " Weekly Wound Progress Report " revealed: ? Date of onset, October 5, 2012, In house acquired; Wound Type: Pressure; Site: R (right) lat (lateral) ankle; Stage/Thickness: Stage III; L (length): 2.3, W (width): 2.3, D (depth): 0; Wound bed: 40% granulation and 60% slough; Impression of (wound) status/treatment orders= New " ? October 8, 2012, Stage/Thickness: Stage III; L= 2.3, W=2.3, D=0; Wound bed: 20% granulation and 80% slough; Impression of (wound) status/treatment orders= no change " A review of the Interim Order Forms revealed: October 5, 2012 at (1:00 PM) directed, " Cleanse open area on right ankle with NSS (normal saline solution), pat dry, apply hydrogel and cover with 4x4 gauze, secure with tape until healed. " October 11, 2012 at (10:10 AM) directed, " D/c (discontinue) wound care for right ankle. Begin -Cleanse open area on right ankle with NSS, pat dry, apply Santyl and cover with DSD until healed. " A review of the October 2012 "Treatment Administration Record " revealed, The order to " Cleanse open area on right ankle with NSS, pat dry, apply hydrogel and with 4x4 gauze secure with tape until healed. " The treatment was done in accordance with the physician's order [REDACTED]. The Team Note dated October 5, 2012 at 2:00 PM revealed, " Resident was noted with an old scar re-open that measure 2 by 2.7. MD (medical doctor) made aware, order given ... " Doctor ' s Progress Notes revealed the following: " October 5, 2012 Pt (patient) has an open area on the rt (right) ankle. Pt has a lot of pressure on the area of this body. Wound rt lateral ankle. Treat with NS (normal saline), apply hydrogel and dressing. Use Bunny boots to keep pressure off rt lateral ankle. Will inform wound nurse for next (Tuesday) ... " October 9, 2012 (Tuesday) Wound Rounds: the sacral wound...The left medial knee ...The left lateral ankle ...The pt has an air mattress and feet were floating off a pillow ... " There was no documented evidence that while the wound nurse provided consultation to the resident, he/she failed to address the wound to the resident ' s right lateral ankle. Through record review facility staff first observed the open area to the right ankle at a Stage III. According to documentation in the "Team Notes" and the "Resident has actual skin breakdown ... " care plan the right ankle was a re-open scar. However, the " Weekly Wound Progress Report " described the wound to the right ankle as pressure related; and the assessment by Employee #18 revealed that the resident has a lot of pressure on this area of (his/her) body. There was no evidence that facility staff addressed interventions and or new approaches to prevent this area from reopening on the aforementioned care plan. The wound was first observed (October 5, 2012) to have 60% slough (A layer or mass of dead tissue separated from surrounding living tissue) and 40% granulation. The treatment prescribed was Hydrogel (wound dressing which is highly absorptive, contours to a wound site and maintains the wound in a moist state to promote healing.) Three (3) days later (October 10, 2012) the wound progressed from 60% slough to 80% slough however there was no change in the treatment (the use of Hydrogel). On October 11, 2012 the treatment order was changed to Santyl (an active enzymatic therapy that continuously removes necrotic tissue from wounds at the microscopic level). There was no evidence that facility staff consistently implemented interventions to ensure that a resident having pressure sores receives necessary treatment and services to prevent new sores from reopening. A face-to-face interview was conducted with Employee #6 on October 26, 2012 at approximately 8:50 AM. He/she acknowledged the findings at the time of the review. The record was reviewed on October 26, 2012.

Based on staff interview and record review for Resident #1 it was determined that facility staff failed to initiate interventions after the resident ' s pressure sores worsened on March 5, 2012 and continued to deteriorate. The findings include: Resident #1 was born on June 21, 1954 and admitted to the facility on [DATE]. According to the Minimum Data Set (MDS) assessment dated [DATE], 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 " Weekly Wound progress Report " the resident ' s was identified with the following wounds: February 27, 2012: Right ankle - 1 cm x 1 cm with 100 % granulation and Right heel - 1 cm x 2 cm with 100% granulation March 5, 2012: Right ankle- 6 cm x 4 cm with 60% granulation and 40% slough and Right heel 5.6 cm x 5.0 cm with 100% granulation. March 12, 2012: Right ankle 6 cm x 4.5 cm with 70% granulation and 30% yellow slough and Right heel 5.4 cm x 5 cm, with 100 % granulation March 19, 2012: Right ankle 7.1 cm x 6.0 cm with 65% granulation and 35% yellow slough and Right heel 5.2 cm x 4.8 cm with 100 % granulation March 26, 2012: Right ankle 7.3 cm x 6.0 cm with 60% granulation and 40% yellow slough and Right heel 5.3 cm x 5.0 cm with 80% granulation and 20% yellow slough. April 3, 2012: Right ankle 9 cm x 8 cm with 20% granulation and 80% yellow slough and Right heel 4 cm x 2 cm with 100% granulation. A telephone order dated February 27, 2012 at 3:20 PM and signed by the physician on March 1, 2012, directed, " 1. Site right ankle: cleanse with NSS (normal sterile saline) and apply hydrogel dressing daily. 2. Site cleanse right heel with NSS and apply hydrogel dressing daily. " A telephone order dated March 29, 2012 at 11:00 AM and signed by the physician on April 1, 2012, directed: " 1.Cleanse right ankle with NSS. Apply Santyl and dressing daily 2. Cleanse right heel with NSS. Apply Santyl and dressing every day. " There was no documentation in the nurses ' notes; physician ' s notes or physician assistant ' s notes to explain why the wound treatment order was changed. There was no evidence in the physician's order [REDACTED]. A telephone order dated March 30, 2012 at 5:00 PM, signed by the physician on April 1, 2012, directed, " Air mattress for the resident. " According to the April 2012 TAR, the resident was placed on the air mattress on April 4, 2012 and it was maintained until the resident was hospitalized on [DATE]. There was no evidence in the record that an air mattress was initiated on March 5, 2012 when the residents ' wounds worsened. A review of the February, March and April 2012 TARs revealed the following order initiated February 14, 2012: " Turn and position every 2 hours. " The resident was turned and repositioned every two (2) hours as evidenced by the nurse ' s initials in the designated box on the TAR. Additionally, the resident was prescribed foam boots (bunny boots) at the same time and according to the above cited TARs the resident was provided with foam boots (bunny boots) as prescribed. A face-to-face interview was conducted with Employee #2 on July 10, 2012 at 12:00 PM. He/she acknowledged that there were no changes in the treatment orders when the wounds worsened on March 5, 2012 and continued to deteriorate until March 29, 2012 when a new treatment was prescribed. The record was reviewed June 26, 2012.

Based on record review and staff interview for one (1) of 18 sampled and one (1) supplemental resident, it was determined that facility staff failed to provide adequate supervision for one (1) resident who was identified as a wanderer. Resident #2. The findings include: The facility staff failed to provide adequate supervision for one (1) resident who was identified as a wanderer; who subsequently eloped and was found sitting on a ledge on the roof of the building. A review of nursing documentation in the clinical record revealed documentation by a nurse which stated, " At approximately 1:00 - 1:05PM this writer was informed by another staff member that Resident (#2) had entered into emergency stairwell on unit 2 North. This writer immediately went to 2 North to look for resident. Resident could not be found. 2 North staff informed to help with search, also 2-South ' s charge nurse assisted. Around 1:20-1:25 PM the resident was found by two staff members sitting on ledge of South side of building (roof). This writer was informed of resident ' s status. (Resident) came back to unit. Assessment of resident; no injury noted. " Employee #5 acknowledged making the aforementioned nursing entry during a face-to-face interview at 3:15PM on February 18, 2011 After the resident ' s elopement episode on February 15, 2011 the resident ' s care plan was amended on February 16, 2011 to include, " Provide one to one (1:1) care to monitor patient (resident) closely and psych consult requested for wandering behavior and episodes of agitation. " A review of the clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Dementia continues to be listed among the resident ' s current [DIAGNOSES REDACTED]. The resident was also coded with a Three (3) for wandering under section E. The score of 3 indicated that the resident displayed wandering behavior daily. A review of physician's order [REDACTED]. The resident was monitored for behaviors of agitation each shift and the results were documented on the behavior monitoring record. A review of the behavior monitoring record for February 2011 revealed the resident exhibited " 0 " (none) episodes of agitation during the month with the exception of the behavior exhibited on February 15, 2011 at 12:45 PM. The resident was medicated with Ativan for the behavior agitation and the result was documented as effective. Documentation in the nurses ' notes indicated that brhaviors prior to the resident ' s elopement indicated that he/she was displaying agitation. The nurse wrote the following statement under the heading of Behavior at 4:30PM on February 15, 2011, " Resident was brought back to unit at 12:45PM by CNA from dining area. CNA informed this writer that resident had become agitated and hit another resident on left shoulder and top of back with plate during lunch. " The nurse ' s documentation continued, " The resident was taken to his/her room for clothing change after observation of clothing being wet. " Review of care plans for elopement on the resident ' s record revealed that a Wander Guard and hourly monitoring was initiated for the resident on June 21, 2010. A review of the hourly monitoring sheet for February 15, 2011 revealed documentation for every hour. At 12:00 Noon the resident was observed in the dining room and at 1:00PM the documentation stated " Elopement. " The following documentation was also written on the monitoring sheet. " Last seen in hallway at 12:45PM " Employee #5 acknowledged that he/she had seen the resident in the hallway at 12:45PM. On January 14, 2011 the following information was added to the care plan under the heading of " Focus: Problematic manner in which resident acts characterized by ineffective coping; wandering related to restlessness, cognitive impairment, inability to locate own room, attempts to leave unit. " The goal was listed as, " Resident will wander only within specified boundaries, " and the interventions were documented as: " Allow resident to wander on unit; Check to ensure resident has a wanderer ' s bracelet on; Document resident ' s whereabouts hourly on wanderers ' checklist and provide assistance in locating own room. " After the resident ' s elopement episode on February 15, 2011 the resident ' s care plan was amended on February 16, 2011 to include, " Provide one to one (1:1) care to monitor patient (resident) closely and psych consult requested for wandering behavior and episodes of agitation. " Per a discussion with Employee #9 at 10:50AM. He/she stated, " A buzzer will sound if the doors to the stairwell are opened but the wander guards will not activate the buzzer. The wander guards will only alarm at the front and side doors on the first floor of the building. " On February 18, 2011 at approximately 10:00AM the resident was observed sitting in a reclining chair in his/her room. The resident appeared asleep. A CNA was seated in a chair beside the resident. The CNA confirmed that the resident was asleep. A face-to-face interview was conducted with Employee #5 at approximately 3:15PM on February 18, 2011. The employee stated that he/she was the resident ' s charge nurse when the elopement occurred and continued, " A Certified Nursing Assistant (CNA) (no name) brought the resident out of the dining room and stated, ' I brought him/her out because he/she is agitated. ' The CNA took the resident to his/her room and toileted him/her. I spoke with the resident and he/she was calm. The CNA brought the resident out of the room and I saw him/her walking in the hall. About 10 minutes later someone called me (no name) and said a nurse from 2S (2 South) reported that a resident went down the stairwell. I immediately started to search for the resident. Two (2) CNAs from my unit and a nurse from the other side joined the search. I went down the stairwell but did not see anyone so I came back to the floor and started searching the rooms. The two CNAs continued to search the stairwell and found the resident sitting on a ledge on the roof. The resident was placed on 1:1 monitoring immediately after the incident. The resident was also being treated for [REDACTED]." Employee #5 confirmed that the resident always wandered from 2N (his/her unit) to 2S but he/she has never known him/her to attempt to leave the floor. A face-to-face meeting was conducted with Employees #6 and #7 at approximately 9:00AM on February 22, 2011. They acknowledged finding the resident on the roof. Employee #6 stated, " Employee #7 and I went to the stairwell. I don ' t know why we went upstairs except that we were trying to think like him/her (the resident) and imagine which way he/she would go. It took us about 20 minutes to find him/her. He/She looked scared but he/she was not hurt. We asked him/her where he/she was going but he/she did not answer. " Employee #7 corroborated Employee #7 ' s statements. He/she also stated, " We watch Resident #2 walk up and down these halls every day. He/she walks over to the South side (unit) every day and walks back but I have never known him/her to try to leave the floor. " A face-to-face interview was conducted with Employee #8 at approximately 9:15AM. The second employee was not available for an interview. Employee #8 stated, " Around 12:30-12:45PM on February 15, 2011 we were having lunch. We heard the door alarm. We opened the door to the lunch room and looked out. We saw no one. I saw a mop and a buffer in the hall but no maintenance tech was in the hall. I assumed that the tech had gone through the door so we went back and continued to eat our lunch. A few minutes later our charge nurse asked us if we had seen the resident. We know the resident because he/she always walks over to our unit and often goes into other residents ' rooms. " The employee was queried as to whether he/she and the other CNA had checked the stairwell and he/she responded, " No. We were not aware that we could enter the stairwell. Had we known that we certainly would have looked in the stairwell. I have never been trained on the door alarm. " A face-to-face interview was conducted with Employee #10 at approximately 9:35AM on February 22, 2011. He/she stated, " I give in-services based on the need of the facility. Orientations are held monthly. I take them (new employees) around to the units and tell them the moment they hear the alarm they are to check the doors. " The employee is new to the position of educator. He/she added, " We will reorient them (the employees) by Friday (2/25/11). He/she continued, " The orientation sheet is not specific to door alarms and there are no written instructions. " A face-to-face interview was conducted with Employee #9 at approximately 10:50AM on February 22. 2011. He/she stated, " I don ' t do a tour. Admission does the tour of the facility. I do orientation on the doors and talk about the door under safety. Stairwell doors are manned by the fire alarm. They (employees) are told to listen for buzzer. They are to go and check the stairwell where the buzzer has alarmed. I also do this for annual in-services. " A face-to-face interview was conducted with Employee #4 at approximately 11:00AM on February 22, 2011. He/she was queried regarding how/why the resident who was a known wanderer was given the opportunity to exit the floor and ascend the stairs to the roof? The employee stated that the resident has never attempted to leave the facility previously and usually never leaves the unit. The employee did not respond when queried regarding an entry in the care plan dated January 14, 2011 which documented the following, " Focus: Problematic manner in which resident acts characterized by ineffective coping; wandering related to restlessness, cognitive impairment, inability to locate own room, attempts to leave unit. " The goal was listed as, " Resident will wander only within specified boundaries, " and the interventions were documented as: " Allow resident to wander on unit; Check to ensure resident has a wanderer ' s bracelet on ... " The facility staff failed to provide adequate supervision for one (1) resident who was identified as a wanderer; subsequently eloped and was found sitting on a ledge on the roof of the facility as evidenced by: The facility staff being unaware of the resident ' s location until they were notified that he/she had entered the stairwell despite being aware that the resident was agitated 10-15 minutes prior to the elopement episode. Facility staff failing to respond promptly and investigate sound of buzzer in thestairwell. Employees #8 & 11 resumed lunch without determining why the buzzer sounded. The facility failed to provide emergency training for the staff regarding the doors and the possibility of wandering residents eloping through the stairwell doors. In a face-to-face interview with Employee #10 at 9:35 AM on February 22, 2011 he/she corroborated the statement made by Employee #8, " I have never been trained on the door alarm. " Employee #10 stated, " The orientation sheet is not specific to door alarms and there are no specific instructions. "